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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