Home - Louisiana Retina

 Patient Medication ListDo you have any allergies to medications: [ ] NO [ ] YESIf yes, please list the medications you are allergic to: _____________________________________________________________________________________________________________________________________________________________________________Please list current eye drops being used:Name of drop:Which eye?How often?Please list current prescribed medications and over the counter medications being used:Name of Medication:Dosage:How often?Please continue to the next page ? Medical History QuestionnaireAre you a previous patient of Dr. Burnham’s from VRI? [ ] No [ ] Yes If yes, what was the date of your last eye exam with him? _________________________Primary reason for today’s (first) visit: ____________________________________________________Who is your primary care physician? _____________________________________________________Who referred you to our office? _________________________________________________________Please mark the conditions you are currently being treated for:[ ] No current conditions[ ] Colitis[ ] Glaucoma[ ] Liver Disease[ ] Anemia[ ] Congestive Heart Failure[ ] Headaches[ ] Lung Disease[ ] Anxiety[ ] COPD[ ] Heart Disease[ ] Lupus[ ] Arthritis[ ] Crohn’s[ ] Heart Murmur[ ] Migraines[ ] Arrhythmia[ ] Depression[ ] Hepatitis[ ] Seizures[ ] Asthma[ ] Diabetes: Type 1[ ] High Blood Cholesterol[ ] Skin Cancer[ ] Bleeding Disorder[ ] Diabetes: Type 2[ ] HIV[ ] Stroke[ ] Cancer[ ] Fibromyalgia[ ] Kidney Disease[ ] Thyroid DisorderAre you pregnant and/or nursing?[ ] No[ ] YesIf yes, how far along? _______________Do you wear glasses?[ ] No[ ] YesDo you wear contact lenses?[ ] No[ ] YesFamily History: (other than yourself): Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: DISEASE/CONDITIONNOYES RELATIONSHIP TO YOUBlindness [ ] [ ]___________________________________________Cataract [ ] [ ] ___________________________________________Crossed Eyes [ ] [ ] ___________________________________________Glaucoma [ ] [ ] ___________________________________________Macular Degeneration [ ] [ ] ___________________________________________Retinal Detachment [ ] [ ] ___________________________________________Diabetes [ ] [ ] ___________________________________________Heart Disease [ ] [ ] ___________________________________________High Blood Pressure [ ] [ ] ___________________________________________Kidney Disease [ ] [ ] ___________________________________________Other: ______________ [ ] [ ] ___________________________________________Please continue to the next page ?Social History: (Please mark all that apply)Smoking: [ ] Current everyday smoker[ ] Former smoker[ ] Never smokedAlcohol use: [ ] None[ ] OccasionalDo you drive? [ ] No [ ] YesIf yes, do you have visual difficulty when driving? [ ] No [ ] YesDo you have visual difficulty while reading? [ ] No [ ] YesDo you have visual difficulty while watching tv? [ ] No [ ] YesPast Ocular History: (Please mark all that apply)[ ] Overall Healthy[ ] Cataracts[ ] Macular Degeneration[ ] Amblyopia (Lazy Eye)[ ] Diabetic Retinopathy[ ] Myopia (Near Sighted)[ ] Aphakia[ ] Dry Eyes[ ] Optic Neuritis[ ] Astigmatism[ ] Glaucoma[ ] Retinal Detachment[ ] Other:____________________________________________________________________________________________________Past Ocular Treatments: (Please mark all that apply)[ ] No prior ocular treatments[ ] Injections: [ ] Avastin [ ] Eylea [ ] Ozurdex [ ] Beovu [ ] Kenalog [ ] Triesence [ ] Lucentis[ ] LaserPast Ocular Surgeries: (Please mark all that apply)[ ] No prior ocular surgery[ ] Cataract Surgery: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________[ ] Corneal Transplant: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________[ ] Epiretinal Membrane: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________[ ] Foreign Body Removal: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________[ ] Glaucoma Stent: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________ [ ] LASIK: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________ [ ] Retinal Detachment: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________[ ] RK: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________ [ ] Vitrectomy: Right eye/Left eye: Date:_______________ Doctor who performed the surgery:____________________ Other Past Surgeries: (Please list all other major surgeries and/or hospitalizations you have had)________________________________________________________________________________________________________________________________________________________________________________________________________________________Ocular Significant Illnesses: (Please mark all that apply) [ ] Overall Healthy[ ] Herpes[ ] Lupus[ ] AIDS[ ] HIV Positive[ ] Multiple Sclerosis[ ] Diabetes[ ] Hypertension[ ] Rheumatoid Arthritis [ ] Graves’ Disease [ ] Hypothyroidism[ ] Sjogren’s[ ] Other: ___________________________________________________________________________________________________Infections: (Please mark all that apply)[ ] Overall Healthy[ ] Histoplasmosis[ ] Syphilis [ ] Hepatitis A/B/C[ ] HIV/AIDS[ ] Toxoplasmosis[ ] Herpes Simplex[ ] Meningitis[ ] Herpes Zoster/Shingles[ ] MRSA[ ] Other: ___________________________________________________________________________________________________Please mark all that apply for your current eye complaints: (Ocular Review of Systems)[ ] No complaints[ ] Double Vision[ ] Eye Injury[ ] Itching[ ] Blurred Vision[ ] Dryness[ ] Eye Pain or Soreness[ ] Loss of Vision[ ] Burning[ ] Excess Tearing/Watering[ ] Flashes[ ] Mucous Discharge[ ] Distorted Vision/Halos[ ] Eye Infection[ ] Floaters[ ] Redness ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download