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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?________________

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Please tell us in your own words what brings you to our office today:________________________________________________________________________________________________

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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.

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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 ___________________

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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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