PATIENT HISTORY

[Pages:1]PATIENT HISTORY

Name: Family Physician: Pharmacy:

Height: Phone #: Phone #:

Weight:

Disease History

Do you smoke? mNo m Yes

packs/day.

Are you a former smoker? mNo m Yes Start Date

End Date

Do you consume alcohol? mNo m Yes How often?

Do you use any recreational drugs? mNo m Yes Do you have or have you had any of the following:

Eyes

m Cataract m Eye trauma / eye injury m Eye turning in/out m Glaucoma

m High Blood Pressure Is it under control?

m Yes m No

m Pacemaker and/or Defibrillator (AICD)

m COPD m Home Oxygen

How much?

m Sleep Apnea / CPAP

m TB (Tuberculosis)

m History of eye surgery m History of head injury/accident m History of retina surgery

Has the unit been checked in the last 3 months?

Other m Anemia m Arthritis/Joint Pain

m History of uveitis m LASIK/PRK or RK m Macular Degeneration Endocrine m Diabetes

m Yes m No m Bladder Problem

Patient Initials

m Blood Disorder

Please bring copy of cardiac implant card.

m Cancer Specify

m Claustrophobia

Is it under control? m I do not check Year Diagnosed

m Rheumatic Fever m Sickle Cell m Stroke

m Delayed emptying of stomach

m End Stage Renal Disease

Do you use insulin?

CNS

On Dialysis?

Blood Sugar Avg

m Bipolar

m GERD

Recent A1C

m Delayed Development m Hepatitis A, B, or C

m Thyroid Problems

m Meningitis

m Herpes

Vascular

m Migraines

m Hiatal Hernia

m Chest Pain m Cholesterol

m Parkinson's

m HIV

m Restless Leg Syndrome m Immune Deficiency

m Circulation Problem m Heart Attack

m Seizures Lung

m Kidney m MRSA

m Heart Disease m Heart Murmur

m Asthma / Use inhaler m Shingles

m Emphysema

m Other

Are you currently experiencing any difficulties/symptoms below? :

General Health : mRecent weight loss m Fever mChills

Ears, Nose, Mouth & Throat : mHearing loss

Cardiovascular : mChest pain or pressure mArrythmia or palpitations mStress test (last 6 months) m A-Fib

On Blood Thinners? Why?

Muscles, Bones & Joints : mJoint pain mRestricted motion in neck mTMJ mMeds for chronic pain

Skin & Integumentary : mRash m Sores m Blisters

Neurological : mNumbness or tingling sensations mSensation loss

Respiratory : m Cough mShortness of breath

Psychiatric : mNervousness, anxiety mDepression

Gastrointestinal (Stomach) : mAbdominal pain mHeartburn / Reflux mBloody stool m Nausea/Vomiting

Recent/Chronic?

Genital, Kidney & Bladder : mFrequent urination m Urgency

Endocrine : mHeat or cold intolerance mExcessive thirst

Hematologic/Lymphatic : mAbnormal Bleeding

Allergy/Immune : mAllergic reaction mRecurrent infections

Have you traveled out of the country in the last 30 days or do you have plans to travel out of the country? mYes m No

Medical allergies AND reaction: NKDA (no known allergies)

LATEX Allergy?

List

Have you ever taken any of these medications for your prostate or blood pressure? m Tamsulosin (Flomax) m Terazosin (Hytrin) m Doxazosin (Cardura) m Afuzosin (Uroxatral) m Siadosin (Rapafo) m Other

a. Do you have any physical restrictions or limitations?

Can you lay flat? mYes m No

b. Please mark any that apply to you: mLoose teeth m Dentures m Bridges m Capped teeth m Hard of hearing m Hearing aid m Stent Placement, Date

c. Do you wear contact lenses? mNo m Yes Last date worn

d. List ALL previous surgeries on YOUR BODY and include dates:

e. Have you or any of your relatives ever had a problem with anesthesia? (High fever, nausea, or trouble waking up) mYes m Relative m No

f. Do any living or deceased relatives have any of the following?

Diabetes mNo m Yes Relation Heart Disease mNo m Yes Relation

High Blood Pressure m No m Yes Relation Macular Degeneration mNo m Yes Relation

Cancer m No m Yes Relation Glaucoma m No m Yes Relation

g. Females Only: Are you pregnant at this time? mYes m No

Have you been pregnant or nursing in the past 6 months? mYes m No

Patient Initials

Date:

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