Irp-cdn.multiscreensite.com



DAIBER VISION CARE MEDICAL HISTORY QUESTIONNAIRENAME ________________________________________________________ DATE __________/__________/_________________ADDRESS ______________________________________________________ HOME PHONE (_______)______________________CITY__________________________ST_______ZIP______________ CELL PHONE (_______)________________________BIRTH DATE ______/______/_______ SSN: _______/________/________ WORK PHONE (_______)______________________MEDICAL DOCTOR/CLINIC: _________________________________________ DR’S PHONE (_______)________________________LAST EYE EXAM_____/_____/_____ LAST MEDICAL EXAM____/_____/_____ PHARMACY USED ____________________________IF PATIENT IS A MINOR/CHILD, PLEASE LIST PARENT/GUARDIAN NAME___________________________________________________EMPLOYER____________________________________ SCHOOL (IF STUDENT)____________________________________________WHO IS IT OK TO DISCUSS YOUR PERSONAL HEALTHCARE INFORMATION WITH? NAME______________________________RELATIONSHIP____________________DOB__________PHONE #__________________ NAME______________________________RELATIONSHIP____________________DOB__________PHONE #__________________OCULAR HISTORYHAVE YOU HAD ANY OF THE FOLLOWING?□ CROSSED EYES□ RETINAL DISEASE □ CATARACTS □ EYE INFECTIONS□ LAZY EYE □ DROOPING EYELID □ FEVER BLISTERS□ SHINGLES □ GLAUCOMA Explanation:__________________________________________________________________________________________________PLEASE LIST ANY OCULAR (EYE) SURGERIES YOU HAVE HAD, INCLUDING DATES: _________________________________________HAS ANYONE IN YOUR FAMILY (Parents, grandparents, siblings, or children) HAD ANY OF THE FOLLOWING?CONDITIONNOYESRELATIONSHIP TO YOU (maternal/paternal grandparent, etc.)BLINDNESS □ □CATARACT □ □CROSSED EYES □ □GLAUCOMA □ □MACULAR DEGENERATION □ □RETINAL DETACHMENT/DISEASE □ □ARTHRITIS □ □CANCER Type: □ □DIABETES □ □HEART DISEASE □ □HIGH BLOOD PRESSURE □ □KIDNEY DISEASE □ □LUPUS □ □THYROID DISEASE □ □OTHER: □ □ARE YOU PREGNANT AND/OR NURSING?□ NO□ YESDO YOU WEAR GLASSES?□ NO□ YES IF YES, HOW OLD ARE THEY?__________________________________DO YOU WEAR CONTACT LENSES?□ NO□ YES IF YES, WHAT KIND ARE THEY?________________________________ TYPE: □ RIGID □ SOFT □ OVERNIGHT WEAR □ OTHER________________ Are they comfortable? □ YES □ NOARE YOU INTERESTED IN CONTACTS TODAY? □ NO □ YESMEDICAL HISTORYLIST ALL MAJOR INJURIES, SURGERIES, AND/OR HOSPITALIZATIONS YOU HAVE HAD: ______________________________________ ____________________________________________________________________________________________________________WHAT MEDICATIONS ARE YOU ALLERGIC TO? □ NO KNOWN DRUG ALLERGIES ____________________________________________________________________________________________________________WHAT MEDICATIONS DO YOU TAKE, INCLUDING OVER THE COUNTER, VITAMINS, AND EYE DROPS?MEDICATIONDOSAGE AMOUNTHOW OFTENREASON TAKINGSOCIAL HISTORYDO YOU DRIVE? □ NO □ YES IF YES, DO YOU HAVE VISUAL DIFFICULTIES WHEN DRIVING? □ NO □ YES DO YOU USE TOBACCO PRODUCTS?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG_________________________________)DO YOU DRINK ALCOHOL?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG_________________________________)DO YOU USE ILLEGAL DRUGS?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG_________________________________)HAVE YOU EVER BEEN EXPOSED TO OR INFECTED WITH: □ GONORRHEA □ HEPATITIS □ HIV □ SYPHILIS □ NONE OF THESEREVIEW OF SYSTEMS Do you currently have (or have you ever had) any problems in the following areas?NOYES NOYESNOYESEYES: LOSS OF VISION □ □CONTITUTIONAL: FEVER, WEIGHT LOSS/GAIN □ □GASTROINTESTINAL: DIARRHEA □ □ BLURRED VISION □ □INTEGUMENTARY: SKIN □ □ CONSTIPATION □ □ DISTORTED VISION/HALOES □ □NEUROLOGICAL: HEADACHES □ □GENITOURINARY: GENITALS/KIDNEY/BLADDER □ □ LOSS OF SIDE VISION □ □ MIGRAINES □ □BONES/JOINTS/MUSCLES: RHEMATOID ARTHRITIS □ □ DOUBLE VISION □ □ SEIZURES □ □ MUSCLE PAIN □ □ DRYNESS □ □ENDOCRINE: THYROID/OTHER GLANDS □ □ JOINT PAIN □ □ MUCUS DISCHARGE □ □EAR, NOSE, MOUTH, THROAT: ALLERGIES/HAY FEVER □ □LYMPHATIC/HEMATOLOGIC ANEMIA □ □ REDNESS □ □ SINUS CONGESTION □ □ BLEEDING PROBLEMS □ □ SANDY OR GRITTY FEELING □ □ RUNNY NOSE □ □ALLERGIC/IMMUNOLOGIC □ □ ITCHING □ □ POST-NASAL DRIP □ □PSYCHIATRIC □ □ BURNING □ □ CHRONIC COUGH □ □EXPLANATION OF ANY CONDITIONS ABOVE:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FOREIGN BODY SENSATION □ □ DRY THROAT/MOUTH □ □ EXCESS TEARING/WATERING □ □RESPIRATORY: ASTHMA □ □ GLARE/LIGHT SENSITIVITY □ □ CHRONIC BRONCHITIS □ □ EYE PAIN/SORENESS □ □ EMPHYSEMA □ □ CHRONIC EYE/LID INFECTION □ □VASCULAR/CARDIOVASCULAR: DIABETES □ □ STYES OR CHALAZION □ □ HEART PAIN □ □ FLASHES OR FLOATERS IN VISION □ □ HIGH BLOOD PRESSURE □ □ TIRED EYES □ □ VASCULAR DISEASE □ □Doctor’s Signature_________________________________________________ Date_____________________________________ ................
................

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

Google Online Preview   Download