Dr. John B. Cox and Dr. Heather Estopinal | 333 Whitesport ...



NAME:__________________BIRTHDATE:________________________REFERRING PHYSICIAN (IF ANY):__________________________________CURRENT EYE PROBLEM:_______________________________________IF YOU DO NOT WANT APPOINTMENT REMINDERS LEFT ON YOUR ANSWERING MACHINE OR WITH ANOTHER PERSON WHO MAY ANSER YOUR PHONE, PLEASE INITIAL HERE:_________________________ALLERGIES:MEDICATIONREACTIONSYSTEMIC MEDICATIONS: (YOU MAY ATTACH A LIST IF NEEDED OR CONTINUE ON THE BACK)MEDICATIONSTRENGTHFREQUENCYOPHTHALMIC MEDICATIONS (EYE DROPS):MEDICATIONSTRENGHTHFREQUENCYEYE (LEFT/RIGHT/BOTH)SOCIAL HISTORY:HEIGHT:___________ WEIGHT:____________DO YOU SMOKE?________________ ARE YOU A FORMER SMOKER?___________HOW MUCH?_________/ DAY / WEEK / MONTHWHEN DID YOU STOP?________________DO YOU DRINK ALCOHOL? NEVEREVERY DAYSOCIALLYFORMER DRINKERDO YOU DRIVE A CAR? YES NODO YOU LIVE ALONE? YES NOREVIEW OF SYSTEMSPAST MEDICAL HISTORYGENERALFEVERCHRONIC FATIGUEWEIGHT LOSS (EXTREME)HYPERCHOLESTEROLEMIAWEIGHT GAIN (EXTREME)FATIGUE (UNUSUAL)OTHER:EYESPAINCATARACTSBLURRY VISIONGLAUCOMAVISION LOSSRETINAL DETACHMENTITCHINGLAZY EYE (AMBLYOPIA)MATTERINGDIABETIC RETINOPATHYFOREIGN BODY MACULAR DEGENERATIONGRITTY SENSATIONSTRABISMUSDRY EYEPSEUDOTUMOR CEREBRITEARINGIRITIS/UVEITISREDNESSFLOATERSGLARE/HALOSFOREIGN BODYFLOATERSOTHER:FLASHING LIGHTSDOUBLE VISIONOTHER:CARDIOVASCULARCHEST PAINHIGH BLOOD PRESSUREMURMURSMITRAL VALVE PROLAPSIRREGULAR HEART BEATATRIAL FIBRILLATIONHEART DISEASECONGESTIVE HEART FAILURENEW PROBLEM:HEART ATTACKOTHER:HEART DISEASEIRREGULAR HEART BEATOTHER:RESPIRATORYCOUGHASTHMAHOASENESSBRONCHITISSHORTNESS OF BREATHEMPHASEMANEW PROBLEM:HAY FEVER/ALLERGIESOTHER:TB (TUBERCULOSIS)OTHER:ENTHEARING LOSSCANCERDRY MOUTHMENIERES DISEASECONGESTIONSINUSITISSORE THROATHEARING LOSSPOST NASAL DRIPOTHER:DIZZINESSTINNITUS (RINGING)BLEEDING IN EARSSINUSITISOTHERENDOCRINEFREQUENT URINATIONDIABETES TYPE 1EXCESS HUNGERDIABETES TYPE 2EXCESS THIRSTTHYROID ABNORMALITIESHEAT INTOLERANCEOTHER:COLD INTOLERANCEOTHERMUSCULOSKELETALSTIFFNESSRHEUMATOID ARTHRITISMUSCLE PAINOSTEOARTHRITISJOINT PAINUNKOWN ARTHRITISARTHRITISFIBROMYALGIAFIBROMYALGIAOTHER:OTHER:GENITOURINARYEVER TAKEN FLOWMAXKIDNEY STONESVIAGRA/CIALIS/LEVITRAPROSTATE PROBLEMS:FREQUENT URINATIONMENAPAUSEBLOOD IN URINEHYSTERECTOMYPAIN ON URINATIONPREGNANTOTHER:OTHER:GIVOMITTINGULCERSDIARRHEACOLITISHEARTBURNDIVERTICULITISNAUSEACROHNS DISEASEDIFFICULTY SWALLOWINGOTHERCONSTIPATIONOTHERSKINITCHINGPSORIASISSCALINGSKIN CANCERRASHROSACEABRUISINGOTHER:HAIR LOSSOTHER:NEUROLOGICALSEIZURESSTROKEPARALYSYSMYASTHENIA GRAVISGAIT PROBLEMSPITUITARY TUMORPARASTHESIASBRAIN TUMORINCOORDINATIONMIGRAINESHEADACHESOTHER:PSYCHIATRICANXIETYANXIETYDEPRESSIONDEPRESSIONMENTAL DISORDEROTHER:HEMATOLOGICANEMIACANCER:BLEEDING TENDENCYANEMIABLOOD DISORDEROTHERLYMPH NODE SWELLINGALL/IMMUNOLOGICSEASONAL ALLERGIESHIVFREQUENT ILLNESSESSEASONAL ALLERGIESFOOD ALLERGIESSYSTEMIC LUPUS ERYTHEMATOSUSOTHER:OTHER:ARE YOU CURRENTLY BEING TREATED FOR ANY ONGOING EYE PROBLEMS, OR HAVE YOU BEEN TREATED FOR ANY CHRONIC EYE PROBLEMS IN THE PAST?EYE (RIGHT/LEFT/BOTHDIEASEONSET-IF KNOWNARMDGLAUCOMADIABETIC EYE DISEASEMACULAR HOLE/PUCKERDRY EYECATARACTALLERGIESBLEPHARITIS/LID DISEASEOTHER:FAMILY HISTORY-- IS THERE A FAMILY HISTORY OF:RELATION (MOTHER/FATHER, ETC)EYE DISEASERELATION (MOTHER/FATHER, ETC)SYSTEMIC DISEASEGLACOMAALZHEIMER'SDIABETESARTHRITISARMDASTHMACATARACTSCANCERSTRABISMUSDIABETESSTROKEEMPHYSEMAOTHER:HEART DISEASEHYPERTENSIONOTHER:PAST OCULAR SURGERIES:EYE (RIGHT/LEFT/BOTH)PROCEDURESURGEONDATE OF SURGERYHAVE YOU EVER HAD ANY TYPE OF SURGERY:PROCEDUREDATE OF SURGERY ................
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