Medical History Questionnaire - Home - Des Plaines Eye ...
Medical History Questionnaire
Please help us help you by answering all questions to the best of your knowledge.
Medicare and Commercial Insurers require this form to be filled out completely to receive benefits.
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Name_____________________________________________________________Date of Birth_____/______/_______
Last First M.I.
Address_______________________________Apt /Lot#_____City___________________State_____Zip Code_________
Telephone_________________E-Mail_______________________________Gender M F Marital Status_______
Ethnicity__________________ Language(s) spoken at home_______________
Social Security#______________________If Minor, Name of Guardian___________________________________
Emergency Contact________________________________Relationship____________Phone#____________________
Insurance Company____________________________Group\I.D.#________________________________________
Occupation_____________________________Employer_______________________________________________
Employer's Address_______________________________City___________________State____Zip Code_________
Employer's Telephone #___________________________Contact:___________________________________________
Name of physician referring you___________________________________Telephone___________________________
Address__________________________________City___________________________State_____Zip Code_________
Date of last Eye Examination___________
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Do you currently have any problems in the following areas?
YES NO YES NO
Eyes
Loss of Vision [ ] [ ] Difficulty driving [ ] [ ]
Poor night vision [ ] [ ] Mucous Discharge [ ] [ ]
Redness [ ] [ ] Previously diagnosed cataracts [ ] [ ]
Surgery to eye muscles [ ] [ ] History of retinal detachment [ ] [ ]
Blurred Vision [ ] [ ] Recurrent infections [ ] [ ]
Difficulty Reading [ ] [ ] Eye pain or soreness [ ] [ ]
Difficulty seeing television [ ] [ ] Glare/Light sensitivity [ ] [ ]
Halos [ ] [ ] Foreign body sensation [ ] [ ]
Excess tearing/watering [ ] [ ] Floaters or spots [ ] [ ]
Loss of side vision [ ] [ ] Itching, burning [ ] [ ]
Double Vision [ ] [ ] Flashing lights [ ] [ ]
Dryness, sandy or gritty feeling [ ] [ ] Tired eyes [ ] [ ]
Sjogren's Syndrome [ ] [ ]
Do you wear glasses?______________How long have you had your current pair?_______________________
Do you wear contacts ?_______What type?_________________How old is current pair?________________
PLEASE CONTINUE ON OTHER SIDE
Please tell us in your own words what brings you to our office today:________________________________________________________________________________________________
_______________________________________________________________________________________________
Medical History If you have now or in the past problems in any of these, please include brief description.
Fever, weight loss____________________________________________________________________________
Ears, Nose, Mouth and Throat__________________________________________________________________
High Blood Pressure__________________________________________________________________________
Heart Disease________________________________________________________________________________
Respiratory__________________________________________________________________________________
Gastrointestinal______________________________________________________________________________
Genitourinary________________________________________________________________________________
Muscles/Bones_______________________________________________________________________________
Skin_______________________________________________________________________________________
Neurological_________________________________________________________________________________
Psychiatric__________________________________________________________________________________
Endocrine___________________________________________________________________________________
Hematologic/Lymphatic (Blood)_________________________________________________________________
Allergic/Immunologic_________________________________________________________________________
Please List All Major Surgeries and Past Illnesses
___________________________________________________________________________________________________________________________________________________________________________________________________________________________
Physician/Internist's Name___________________________________________________________
Family History
Are there any health problems or diseases that run in your family? (Including cataracts, glaucoma, macular degeneration) If so, please state the condition and family member.
__________________________________________________________________________________
__________________________________________________________________________________
PLEASE CONTINUE ON NEXT PAGE
Social History
Do you drink alcohol?_______If "YES", how many glasses a day?___________________________
Do you use tobacco?________If "YES", how much daily?__________________________________
Have you ever used tobacco?_______ If “YES”, When/how long ago did you stop using it?_______________
If you were a past tobacco user, what methods were used to help stop?______________________________
Do you use caffeine (coffee, tea, soda)?________If "YES", how much a day?___________________
Do you use illegal drugs?_________ Do you engage in regular exercise?__________
Do you use nutritional supplements/vitamins?____________
Current Height ______Ft______In Current Weight _______Lbs
Please list all medications currently using. Include all strengths, dosages, and their purpose:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DO YOU NOW, OR HAVE YOU EVER TAKEN FLOMAX? YES NO
Are you allergic to any medications? If "YES", please list all, and what type of reaction you had to each medication listed.
__________________________________________________________________________________________________________________________________________________________________________
Pharmacy Info: Please provide us with contact information of where you most frequently fill your prescriptions:
Pharmacy (or Mail Order) Name__________________________
Address _______________________
Tel. Number ___________________
PLEASE CONTINUE ON OTHER SIDE
I acknowledge that I am responsible for this account. All information provided by me is to the best of my knowledge true and complete, and any false or misleading information provided by me releases Des Plaines Eye Physicians & Surgeons, Ltd. and all its' entities from any liability. I request that payment of authorized insurance benefits be made either to me or on my behalf to the organization listed below for any equipment or services provided to me by that organization. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services.
Signed______________________________________________Date___________________________
Physicians signature___________________________________________________________________________
Des Plaines Eye Physicians and Surgeons, Ltd.
John W. Winkler, M.D.
Edward G. Dolezal, M.D.
940 Lee Street
Des Plaines, Il 60016
Telephone (847)299-5501
Fax(847)299-5505
goodeyes@
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