DATE · 2020. 9. 29. · diabetes Yes No heart disease Yes No high blood pressure Yes No kidney...
Transcript of DATE · 2020. 9. 29. · diabetes Yes No heart disease Yes No high blood pressure Yes No kidney...
MEDICAL HISTORY
Do you have any allergies to medications? Yes No If yes, explain:List any medications you take and what conditions you take them for (Including eyedrops, oral contraceptives, aspirin, over the counter medications,home remedies, vitamins)
List all major surgeries and/or hospitalizations you have had:
Check any of the following that you have had:
crossed eyes lazy eye drooping eyelid prominent eyes macular degeneration glaucoma
Describe further:
SPECTACLES HISTORY
Do you wear glasses? Yes No If yes, how old is your current prescription? Do you wear them full time part time Type of Glasses
distance reading computer/o�ce If yes, speci�c anti-glare tinits or coatings? Yes No single vision bifocals trifocals progressivesback up safety sports sun If yes, are they prescription sunglasses? Yes No special eyewear needs occupational (mechanics, plumbers, pilots) safety Glasses (gardening, woodworkings, welding) sports/hobbies (raquet sports, motorcycle)
Contact Lens HistoryHave you ever tried to wear contacts? Yes NoIf not a contact lens wearer, are you interested in trying contacts at this time? Yes NoDo you currently wear contacts lenses? Yes NoType and brand of current contact lenses: rigid, soft, extended wearBrand:How often do you wear your contacts? Hour per day/times per weekAt what point of the day do they get uncomfortable?What colution do you use?Please rate the following on a scale of 1 to 10, with 1 being poor to 10 being excellent:lens comfort R Ldistance vision R Lnear vision R LNS - you have something written... “something I cannot ready” drop
Family Historynote any family history (parents, grandparents, siblings, children; living or deceased) for thefollowing conditions.
Disease/Conditionyes/no (relationship to you)blindness Yes No cataract Yes Nocrossede eyes Yes Noglaucoma Yes Nomacular degeneration Yes Noretinal detachment or disease Yes Noarthritis Yes Nocancer/type Yes Nodiabetes Yes Noheart disease Yes Nohigh blood pressure Yes Nokidney disease Yes Nolupus Yes Nothyroid disease Yes Noother:
Social HistoryThis information is kept strictly con�dential. You may discuss this portion directly with the doctorif you prefer.Yes, I would prefer to discuss my social history information directly with my doctor
Do you drive? Yes NoIf yes, do you have visual di�culty when driving?If yes, please describe:
Do you use tobacco products? Yes NoIf yes, type/amount/how longDo you drink alcohol? Yes NoIf yes, type/amount/how longDo you use illegal drugs? Yes NoIf yes, type/amount/how longDo you drink ca�einated drinks? Yes NoIf yes, what kind, volume and how often?Do you drink sweet drinks? Yes No(e.g., soda, juice,sweetened co�ee/tea)If yes, what kind, volume and how often?Do you engage in regular exercise? Yes NoIf yes, how often? Min/hour per week?Have you ever been exposed to or infected by Gonorrhea Yes NoHepatitis Yes NoHIV Yes NoSyphilis Yes NoWhat are your hobbies/ interests/activiteindoor and outdoorAre you a student? Yes NoIf yes, favorite subject(s)least favorit subjectgrade levelschool distict
Review of SystemsDo you currently, or have you ever routinely had any problems in the following areas?yes/no/explainSystemConstitutional fever, weight loss/gain Yes NoIntegumentary (skin) Yes NoNeurolo�cal Yes Noheadaches Yes Nomigraines Yes Noseizures Yes NoEyesloss of vision Yes Noblurred vision Yes Nodistorted vision/halos Yes Noloss of side vision Yes Nodouble vision Yes Nodryness Yes Nomucous discharge Yes Noredness Yes Nosandy or gritty feeling Yes Noitching Yes Noburning Yes Noforeign body sensation Yes Noexcess tearing/watering Yes Noglare/light sensitivity Yes Noeye pain or soreness Yes Nochronic infection, eye or lid Yes Nosties or chalazion Yes No�ashes, �oaters in vision Yes Notired eyes Yes No
Endocrinethyroid/other glands Yes NoReproductive Yes NoPregnant Yes NoIf yes, weeks alongEars, Nose, Mouth, Throatallergies/hay fever Yes Nosinus congestion Yes Norunny nose Yes Nopost-nasal drip Yes Nochronic cough Yes Nodry throat/mouth Yes NoRespiratory Yes Noasthma Yes Nochronic bronchitis Yes Noemphysema Yes NoVascular/Cardiovascular Yes Nodiabetes Yes Noheart pain Yes Nohigh blood pressure Yes No vascular disease Yes Nohigh cholesterol Yes NoGastrointestinaldiarrhea Yes Noconstipation Yes NoGenitourinary Yes Nogenitals/kidney/bladder Yes NoBones/Joints/Musclesrheumatoid arthritis Yes Nomuscle pain Yes Nojoint pain Yes NoLymphatic/Hematologicanemia Yes Nobleeding problems Yes NoAllergy Yes NoAuto-Immune Yes NoPsychiatricYes NoOther:
If you answered YES to any of the above or have a condition not listed, please explain and listmedications:
Patient Signature/Date Doctor’s Signature/Date
(4 lines for patient signature and date and doctor initial)
Patient Name ______________________________________________________________________________________
Dr. Mr. Mrs. Ms. Preferred Name / Nickname ___________________________________________________________________________________ Address _________________________________________________________________________________________
City _____________________________________________________________ Zip Code ______________________
Primary Phone __________________________________ Secondary Phone _________________________________
Email __________________________________________________________________________________________
Date of Birth _______________________________________ SS# (Last Four Digits Only) ______________________________
Genetic Sex: Pronouns: Male Female He/Him/His She/Her/Hers They/Them/Theirs Other _________________________
Preferred Language________________________________ Race __________________________________________
Occupation _____________________________________________________________________________________
Emergency Contact / Relationship ____________________________________ Phone __________________________
Patient Guardian (If Applicable) ______________________________________ Phone_______________________________
VISON INSURANCE If possible, please bring insurance card to your appointment
Carrier_________________________________________ ID Number ______________________________________ (if you have one, please bring your card to appointment)
If patient is not the primary member on insurance, please provide:
INSURED ‘S NAME ___________________________________________ DOB _______________ SS# (LAST 4 DIGITS ONLY) _______________
Date of Last Eye Exam ______________________________________________________________________________
Doctor/Practice ________________________________________________ Phone_____________________________
HEALTH INSURANCE Please bring insurance card to your appointment
Carrier_________________________________________ ID Number ______________________________________ (if you have one, please bring your card to appointment)
If patient is not the primary on insurance, please provide:
INSURED ‘S NAME ___________________________________________ DOB _______________ SS# (LAST 4 DIGITS ONLY) _______________
Date of Your Last Medical Exam ________________________________________________________________________
Doctor /Practice ______________________________________________ Phone ____________________________
DATE ___________________________________________
PATIENT INFORMATION FORMPAGE 1
MEDICAL HISTORY
Do you have any allergies to medications? No Yes: ___________________________________________________
List any medications you take and what conditions you take them for (including eyedrops, oral contraceptives,pain medication, over the counter medications, home remedies, vitamins):
List all major surgeries and/or hospitalizations you have had and when: _________________________________________
Check any of the following that you have had:
crossed eyes lazy eye drooping eyelid
Describe further: _______________________________________________________________________________________
SPECTACLES HISTORY
Do you wear glasses? Yes No If yes, how old is your current prescription? ______ Do you use them full time part time
CONTACT LENS HISTORY If not a contact lens wearer, are you interested in trying contacts at this time? No Yes
Do you currently wear contacts? No Yes: Type: rigid scleral soft extended wear If yes, what brand? _________________________________________________________________________________________
How often do you wear your contacts: Hours per day ___________________ Times per week ___________________
What kind of contact solution do you use? _______________________________ Do you use arti�cial tears? No Yes
Please rate the following on a scale of 1 to 10 (with 1 being poor to 10 being excellent): LENS COMFORT______________ DISTANCE VISION______________ NEAR VISION______________
At what point of the day do they get uncomfortable? _______________________________________________________
cataracts eye injury eye surgery
prominent/bulging eyes dry eye glaucoma
retinal detachment macular degeneration eye infections
bifocals/trifocals/progressives computer/o�ce occupational / safety
back up/emergency glasses sun If yes, are they prescription sunglasses? Yes sports
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____________________________________________________________________________________________________
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____________________________________________________________________________________________________
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Check the types of Glasses you use:
close / reading far / distance bifocals/trifocals/progressives
REVIEW OF SYSTEMSDo you currently, or have you ever routinely had any problems in the following areas?
CONSTITUTIONAL fever, weight loss/gain............Yes NoIntegumentary (skin)...............Yes NoNeurological.................................Yes Noheadaches....................................Yes Nomigraines......................................Yes Noseizures..........................................Yes No
EYESloss of vision................................Yes Noblurred vision..............................Yes Nodistorted vision/halos..............Yes Noloss of side vision.......................Yes Nodouble vision..............................Yes Nodryness..........................................Yes Nomucous discharge.....................Yes Noredness..........................................Yes Nosandy or gritty feeling..............Yes Noitching............................................Yes Noburning.........................................Yes Noforeign body sensation...........Yes Noexcess tearing/watering.........Yes Noglare/light sensitivity................Yes Noeye pain or soreness.................Yes Nochronic infection, eye or lid...Yes Nostyes or chalazion...................... Yes No�ashes/�oaters in vision.........Yes Notired eyes......................................Yes No
ENDOCRINEThyroid/other glands.....Yes NoReproductive.....................Yes NoPregnant Currently..............Yes NoIf yes, how many weeks along: ____
EARS, NOSE, MOUTH, THROAT allergies/hay fever............Yes Nosinus congestion..............Yes Norunny nose.........................Yes Nopost-nasal drip..................Yes Nochronic cough...................Yes Nodry throat/mouth............Yes No
RESPIRATORYasthma.................................Yes Nochronic bronchitis............Yes Nosleep apnea........................Yes No emphysema.......................Yes No
VASCULAR/CARDIOVASCULAR diabetes......................................................heart pain............................high blood pressure.........vascular disease.................high cholesterol.................heart attack .........................stroke ...................................
BONES/JOINTS/MUSCLESrheumatoid arthritis..................Yes Nomuscle pain..................................Yes Nojoint pain.......................................Yes No
LYMPHATIC/HEMATOLOGICanemia.............................................Yes Nobleeding problems.......................Yes No
ALLERGIES.........................................Yes No
AUTO-IMMUNE..............................Yes No
PSYCHIATRIC....................................Yes No
GASTROINTESTINALInfammatory Bowel Disease......Yes No diarrhea............................................Yes Noconstipation.....................................Yes Nogenitals/kidney/bladder.............Yes No
OTHER OR EXPLANATIONS:___________________________________________________________________________________________________
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No YesNo YesNo YesNo YesNo YesNo Yes
No YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes
No YesNo YesNo Yes_______
No YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes
No YesNo YesNo YesNo YesNo YesNo YesNo Yes
No YesNo YesNo Yes
No YesNo YesNo Yes
No Yes
No Yes
No Yes
No YesNo YesNo YesNo Yes
blindness .............................. ______________________________________________________________________________________________________
cataract ................................. ________________________________________________________________________________________________
crossed eyes ........................ _________________________________________________________________________________________glaucoma ............................. ________________________________________________________________________________________macular degeneration ..... ______________________________________________________________________________________retinal detachment .......... _________________________________________________________________________________________arthritis ........................................_________________________________________________________________________________________auto immune disease ..........________________________________________________________________________________________cancer ..................................... ________________________________________________________________________________________diabetes ................................ _________________________________________________________________________________________heart disease ......................._______________________________________________________________________________________high blood pressure .......... ______________________________________________________________________________________high cholesterol ........................................________________________________________________________________________________thyroid disease .......................________________________________________________________________________________________stroke ......................................................___________________________________________________________________________________ other ......................................................___________________________________________________________________________________
To what? _____________________________________________________
No YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes
No YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes
If yes, which relatives?
FAMILY HISTORYNote any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
indoor __________________________________________ outdoor ___________________________________________
SOCIAL HISTORY
This information is kept strictly con�dential. Check this box if you prefer to discuss this portion directly with the doctor: YES I would prefer to discuss my social history information directly with my doctor
Do you drive? No YesIf yes, do you have visual di�culty when driving? No Yes: please describe: ______________________________________________
Do you use tobacco products? No Yes: type/amount/number of years? ___________________________________________
Do you drink alcohol? No Yes: type/amount/number of years? ___________________________________________________
Do you use illegal drugs? No Yes: type/amount/number of years? _________________________________________________
Do you drink ca�einated drinks? No Yes: what kind, volume and how often? ______________________________________
Do you drink sweet drinks? No Yes: what kind, volume and how often? ____________________________________________e.g., soda, juice, sweetened co�ee/tea)
Do you engage in regular exercise? No Yes: what kind(s)? how often? Min/hour per week?
_______________________________________________________________________________________________________________
What are your hobbies/ interests/activites:
Are you a student? No Yes: what grade level / school ? ___________________________________________________
Have you ever been exposed to or infected by: Gonorrhea......... Hepatitis............ HIV....................... Syphilis ............. Chlamydia.........
Review of SystemsDo you currently, or have you ever routinely had any problems in the following areas?yes/no/explainSystemConstitutional fever, weight loss/gain Yes NoIntegumentary (skin) Yes NoNeurolo�cal Yes Noheadaches Yes Nomigraines Yes Noseizures Yes NoEyesloss of vision Yes Noblurred vision Yes Nodistorted vision/halos Yes Noloss of side vision Yes Nodouble vision Yes Nodryness Yes Nomucous discharge Yes Noredness Yes Nosandy or gritty feeling Yes Noitching Yes Noburning Yes Noforeign body sensation Yes Noexcess tearing/watering Yes Noglare/light sensitivity Yes Noeye pain or soreness Yes Nochronic infection, eye or lid Yes Nostyes or chalazion Yes No�ashes, �oaters in vision Yes Notired eyes Yes No
Endocrinethyroid/other glands Yes NoReproductive Yes NoPregnant Yes NoIf yes, weeks alongEars, Nose, Mouth, Throatallergies/hay fever Yes Nosinus congestion Yes Norunny nose Yes Nopost-nasal drip Yes Nochronic cough Yes Nodry throat/mouth Yes NoRespiratory Yes Noasthma Yes Nochronic bronchitis Yes Noemphysema Yes NoVascular/Cardiovascular Yes Nodiabetes Yes Noheart pain Yes Nohigh blood pressure Yes No vascular disease Yes Nohigh cholesterol Yes NoGastrointestinaldiarrhea Yes Noconstipation Yes NoGenitourinary Yes Nogenitals/kidney/bladder Yes NoBones/Joints/Musclesrheumatoid arthritis Yes Nomuscle pain Yes Nojoint pain Yes NoLymphatic/Hematologicanemia Yes Nobleeding problems Yes NoAllergy Yes NoAuto-Immune Yes NoPsychiatricYes NoOther:
If you answered YES to any of the above or have a condition not listed, please explain and listmedications:
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Herpes................................Chicken Pox / Shingles....SARS/COVID .......................MRSA .....................................Fungal Infection.................
PLEASE SIGN:
PATIENT SIGNATURE ___________________________________________________ DATE ____________________________
DOCTOR SIGNATURE ___________________________________________________ DATE ____________________________
No Yes ___________________No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________
No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________
favorite subject(s) _______________________________ least favorite subject(s) _______________________________