Danville San Ramon Eye Medical, Corp



Danville San Ramon Eye Medical, Corp.

Claudia S. Pinilla, M.D., Rupinder K. Mann, M.D.

Patient Name: ___________________________

DOB: _____/___/_______

Date ____/____/________

Referring Physician: PAGE 1 (TURN OVER) PAGE 2

List any medications you currently take INCLUDING eye drops

Reason for your visit today: [pic] Routine Eye Exam [pic] Medical Visit

Do you have allergies to any medications: [pic] Yes [pic] No

If YES, list drug allergies

PERSONAL PAST HISTORY: Have you ever had the following diseases?

YES NO YES NO

[pic] [pic] Glaucoma (eye - right left) [pic] [pic] Emphysema

[pic] [pic] Cataract (eye - right left) [pic] [pic] Asthma

[pic] [pic] Retinal detachment (eye - right left) [pic] [pic] Pneumonia

[pic] [pic] Eye injury (eye - right left) [pic] [pic] Hepatitis

[pic] [pic] Eye infection (eye - right left) [pic] [pic] Arthritis

[pic] [pic] Diabetes [pic] [pic] Thyroid problems

[pic] [pic] High Blood Pressure [pic] [pic] Multiple Sclerosis

[pic] [pic] Stroke [pic] [pic] Epilepsy

[pic] [pic] Heart Attack [pic] [pic] Tuberculosis or TB

[pic] [pic] Coronary Artery Disease [pic] [pic] Migraine headaches

[pic] [pic] Congestive Heart Failure [pic] [pic] Ulcers of stomach

[pic] [pic] Cancer [pic] [pic] Herpes

[pic] [pic] Anemia [pic] [pic] Shingles

[pic] [pic] Venereal Disease (STD) [pic] [pic] Lupus

[pic] [pic] Illicit drug use (explain):______ [pic] [pic] Have you been

[pic] [pic] Are you pregnant? Exposed to the AIDS virus (HIV?)

List all major illnesses or injuries, or surgery not described above:

SOCIAL HISTORY Current occupation

Do you smoke? [pic] YES [pic] NO Do you drink alcohol? [pic] YES [pic] NO

If YES, how many packs a day? If YES, how often?

Do you drive? [pic] YES [pic] NO Do you currently wear glasses?

[pic] YES [pic] NO

Do you have visual difficulty when driving? Have you ever lived outside the USA?

[pic] YES [pic] NO [pic] YES [pic] NO

Have you ever had a blood transfusion?

[pic] YES [pic] NO When: Where?

FAMILY HISTORY: Has anyone in your family had:

[pic] Diabetes [pic] Cancer [pic] Glaucoma

[pic] Migraine Headache [pic] Stroke [pic] Blindness

[pic] Heart Disease [pic] Tuberculosis [pic] High Blood Pressure

Patient Name: ____________________

DOB: ____/____/_______

PATIENT HISTORY PAGE 2

REVIEW OF SYSTEMS: Do you currently have any problems in the following areas?

Constitutional Symptoms

YES NO Skin

[pic] [pic] Fever YES NO

[pic] [pic] Weight Loss/Poor Appetite [pic] [pic] Easy bruising

[pic] [pic] Fatigue/Tire Easily [pic] [pic] Rashes/Facial acne

Eyes Neurological

YES NO YES NO

[pic] [pic] Loss of vision [pic] [pic] Severe headache

[pic] [pic] Distorted vision [pic] [pic] Numbness or tingling of

[pic] [pic] Double vision extremities

[pic] [pic] Floating objects in vision [pic] [pic] Seizures

[pic] [pic] Flashing lights [pic] [pic] Depression/Psychiatric

[pic] [pic] Dryness of eyes conditions

[pic] [pic] Redness

[pic] [pic] Itching Cardiovascular (heart/blood vessels)

[pic] [pic] Burning YES NO

[pic] [pic] Excess Tearing [pic] [pic] Chest pain

[pic] [pic] Glare/Light Sensitivity [pic] [pic] Irregular heart beat

[pic] [pic] Eye pain or soreness

[pic] [pic] Crossed Eyes Respiratory

[pic] [pic] Lazy eye (amblyopia) YES NO

[pic] [pic] Past eye surgery [pic] [pic] Chronic bronchitis/emphysema

Type of surgery [pic] [pic] Chronic cough

[pic] [pic] Shortness of breath

Ears, Nose, Mouth, Throat Gastrointestinal

YES NO YES NO

[pic] [pic] Recent viral infection [pic] [pic] Stomach pain

[pic] [pic] Sore throat [pic] [pic] Diarrhea

[pic] [pic] Loss of hearing or deafness

[pic] [pic] Dryness of mouth Genitourinary (genitals/kidney/bladder)

YES NO

Endocrine [pic] [pic] Burning with urination

YES NO [pic] [pic] Genital sores

[pic] [pic] Thyroid problems [pic] [pic] Kidney infection or bleeding

Allergic - Immunologic Musculoskeletal

YES NO YES NO

[pic] [pic] Hay Fever symptoms [pic] [pic] Muscle or neck pains

[pic] [pic] Skin or respiratory [pic] [pic] Back pain or stiffness

[pic] [pic] Joint pains or stiffness

Patient’s Signature: Date: _____/_____/______

Physician’s Signature: ___________________________ Date: ____/______/______

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