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: ____/______/______
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- syneos health corp address
- american honda finance corp lienholder
- access financial corp atlanta ga
- eye drops for pink eye prescription
- pacific marine corp credit union
- fmr corp boston
- international business machines corp. profitability ratios
- fairfield dodge danville pa
- danville pa jeep dealership
- eye surgery medical term
- anderson financial services danville va
- university of california san francisco medical school