Eye Diseases - Kosnoski Eye
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|Primary Care Physician | |
|Name: | | |
|Address: | |Phone : |
|Referring Physician | |
|Name: | | |
|Address: | |Phone : |
| | |
|Health History | |
|What is the main reason for today’s exam?| | |
|When was your last exam? | | |
|Past Surgeries: | | |
| | | |
|Major Illnesses: | | |
| | | |
|Allergy History: | | |
| | | |
|Current Medications: | | |
| | | |
| | | |
|Eye Diseases | |Notes |
|Amblyopia | Yes No | |
|Blepharitis | Yes No | |
|Blindness | Yes No | |
|Cataract(s) | Yes No | |
|Color Blindness | Yes No | |
|Diabetic Retinopathy | Yes No | |
|Dry Eye Syndrome | Yes No | |
|Eye Injuries | Yes No | |
|Glaucoma | Yes No | |
|Glaucoma Suspect | Yes No | |
|High Risk Medication | Yes No | |
|Macular Degeneration | Yes No | |
|PVD | Yes No | |
|Retinal Detachment | Yes No | |
|Strabismus | Yes No | |
|Other | Yes No | |
|Additional Notes: | | |
|Current Eye Symptoms |Notes |
|Asthenopic | | |
|Glare Sensitivity | Yes No | |
|Headaches | Yes No | |
|Light Sensitivity | Yes No | |
|Tired Eyes | Yes No | |
|Physiologic | | |
|Burning | Yes No | |
|Dryness | Yes No | |
|Epiphora | Yes No | |
|Eyelid Swelling | Yes No | |
|Eye Pain or Soreness | Yes No | |
|Foreign Body Sensation | Yes No | |
|Infection of Eye Lid | Yes No | |
|Itching | Yes No | |
|Mucous | Yes No | |
|Ptosis (Drooping Eyelid) | Yes No | |
|Redness | Yes No | |
|Sandy or Gritty Feeling | Yes No | |
|Visual Symptoms | | |
|Blurred Vision Distance | Yes No | |
|Blurred Vision Near | Yes No | |
|Distorted Vision | Yes No | |
|Double Vision | Yes No | |
|Flashes of Lights | Yes No | |
|Floaters or Spots | Yes No | |
|Fluctuating Vision | Yes No | |
|Loss of Central Vision | Yes No | |
|Loss of Side Vision | Yes No | |
|Loss of Vision | Yes No | |
|Other | Yes No | |
|Additional Notes: | |
|Review of Systems – Brief | Last Health Exam: ______________ | Notes |
|Constitutional Symptoms (fever, weight loss, etc.) | Yes No | |
|Ear, Nose Throat, Mouth | Yes No | |
|Cardiovascular (heart, hypertension, etc.) | Yes No | |
|Respiratory (asthma, emphysema, etc.) | Yes No | |
|Gastrointestinal | Yes No | |
|Genital, Kidney, Bladder | Yes No | |
|Muscles, Bones, Joints (arthritis, etc.) | Yes No | |
|Skin (rash, itching, skin cancer, etc.) | Yes No | |
|Neurological (multiple sclerosis, etc.) | Yes No | |
|Psychiatric (anxiety, depression, etc.) | Yes No | |
|Endocrine (diabetic, hypothyroid, etc.) | Yes No | |
|Blood/Lymph (anemia, cholesterol, etc.) | Yes No | |
|Allergic/Immunologic (seasonal allergies, lupus, etc.) | Yes No | |
|Pregnant | Yes No | |
|Nursing | Yes No | |
|Additional Notes: | | |
| | | |
|HbA1C |
| % | | |
|Family History |
|Eye Diseases | |Relationship to Patient |Notes |
|Amblyopia (Lazy Eye) | Yes No | | |
|Blindness | Yes No | | |
|Cataract(s) | Yes No | | |
|Color Blindness | Yes No | | |
|Eye Tumors | Yes No | | |
|Glaucoma | Yes No | | |
|Glaucoma Suspect | Yes No | | |
|Macular Degeneration | Yes No | | |
|Retinal Detachment | Yes No | | |
|Strabismus (Eye Turn) | Yes No | | |
|Other Eye Conditions | Yes No | | |
|Systemic Diseases | | | |
|Arthritis | Yes No | | |
|Cancer | Yes No | | |
|Diabetes | Yes No | | |
|Heart Disease | Yes No | | |
|High Blood Pressure | Yes No | | |
|Kidney Disease | Yes No | | |
|Lupus | Yes No | | |
|Stroke | Yes No | | |
|Thyroid Disease | Yes No | | |
|Other Diseases | Yes No | | |
|Additional Notes: | | | |
| | | | |
|Social History - General |
|Current |Years: |Employer: |
|Occupation: | | |
|Do you drink alcohol? | No Occasional 1 per day 2-3 per day 4+ per day |
|Do you smoke? | No Occasional 1/2 pack / day 1 pack / day 1+ pack / day |
|Past smoker? | Yes No |When did you |
| | |quit smoking? |
|Tobacco use cessation intervention, | Yes No |Tobacco cessation pharmacologic therapy? | Yes No |
|counseling? | | | |
|Do you chew tobacco? | Yes No |Do you use nutritional supplements (vitamins etc.)? | Yes No |
|Do you use illegal drugs? | Yes No |Do you engage in regular exercise? | Yes No |
|Ethnicity: |Marital |
| |Status: |
| |
| |
| |
|Social History - Vision |
|Computer Used? | Yes No |Hours per day: |Distance from computer: | |
|Do you drive? | Yes No |Daily Mileage: |Do you have visual difficulty when | Yes No |
| | | |driving? | |
|Do you have glare problems?| Yes No |Do you have any problems with night vision? | Yes No |
|Social History - Spectacles |
|Do you currently wear | Yes No |Since: | Full Time Part Time Distance Close |
|glasses? | | | |
|Glasses owned | Single Vision | Safety Glasses | Bifocals | Sports Glasses |
| |Trifocals |Progressive |Back-up Glasses |Other: |
|Have you had trouble in the past with | Yes No |If yes, please explain: |
|glasses? | | |
|Do you wear sunglasses? | Yes No |Are your sunglasses your current prescription? | Yes No |
|Special Eyewear Needs | Computer (special prescriptions, special anti-glare tints or coatings) |
| |Safety Glasses (gardening, woodworking, welding) |
| |Occupational (mechanics, plumbers, pilots) |
| |Sports/Hobbies (racquet sports, motorcycle) |
|Hobbies/Interests: |
Social History-Contact Lenses
| |
|Have you tried to wear contact lenses? Yes No Reason for stopping? |
| |
|If not a contact lens wearer, are you interested in contact lenses at this time? Yes No |
| |
|Do you currently wear contact lenses? Yes No If yes, since: |
| |
|Type and brand of contact lenses: |
| |
|How many hours/day? How many days/week? Today’s wearing time: |
| |
|What contact lens solution do you use? |
|Please rate the following on a scale of 1-10 with 1 being poor and 10 being excellent: |
|Lens comfort: R: L: Distance vision: R: L: Near vision: R: L: |
|History Reviewed: |
| No changes |Initials: |Last History Date: |Date: |
|Changes as noted | | | |
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