New Patient History

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    Name:

    1. Do you have, or have you ever had:

    Condition
    Date of Onset
    and/or Details
  1. Diabetes Mellitus:
  2.  Yes No
    Treatment:
  3. Medical Complications:
  4. Heart Attack
  5.  Yes No
    Angina or Chest Pain  Yes No
    Heart Failure  Yes No
    Irregular or Rapid Heartbeat  Yes No
    Cardiac Pacemaker Inserted  Yes No
  6. High Blood Pressure
  7.  Yes No
  8. A Stroke or “Shock”
  9.  Yes No
  10. Anemia
  11.  Yes No
  12. Asthma
  13.  Yes No
    Emphysema and/or Bronchitis  Yes No
    Pneumonia  Yes No
    Tuberculosis  Yes No
  14. Liver Disease or Jaundice
  15.  Yes No
  16. Stomach or Duodenal Ulcer
  17.  Yes No
  18. Kidney Stones or Other Disease
  19.  Yes No
  20. Arthritis (if yes, type)
  21.  Yes No
  22. Cancer or Tumor
  23.  Yes No
  24. Thyroid Disease
  25.  Yes No
  26. Seizures or Nervous Breakdown
  27.  Yes No
  28. Varicose Veins / Blood Clots in Legs
  29.  Yes No
  30. Bleeding Disorders
  31.  Yes No
  32. Transfusions of Blood or Plasma
  33.  Yes No
  34. TAIDS, ARC, or HIV Positive Test
  35.  Yes No
  36. Other Medical Problems
  37.  Yes No

    Have you traveled to West African countries: Guinea, Nigeria, Sierra Leone, Liberia, Sengal, or Democratic Republic of the Congo in the past 21 days?  Yes No
       
    Have you been in physical contact or cared for anyone with diagnosed or suspected to have Ebola virus disease?  Yes No
       
    Have you had a fever ( > 100.4 F) plus any one of the following symptoms: diarrhea, vomiting, headache, weakness, muscle pain, abdominal pain, or hemorrhaging?  Yes No
       

    2. Are you allergic to any medications or to any foods?

     Yes No
    If yes, please describe the substance(s), with date and type of reaction:

    3. What other medications do you take regularly?

    When did you last use aspirin, in any form?

    4. Have you had any previous eye surgery/laser, or injuries?

     Yes No

    5. What non-ocular operations have you had? Please give type(s) and date(s):


    6. Are you a smoker?

     Yes No
    If yes, how many cigarettes per day?
    If no, and you smoked in the past, when did you stop?

    7. Substance Abuse

    Alcohol?  Yes No  Moderate Daily
    Drug Abuse?  Yes No

    8. Have you gained or lost more than ten pounds in the past year?

     Yes No
    If yes, how many pounds have you gained? or lost?
    Please Explain:

    9. Among blood relatives, is there a history of any of the following:

    a. Glaucoma  Yes No
    b. Cataracts  Yes No
    c. "Lazy Eye" or Muscle Imbalance  Yes No
    d. Retinal Disease  Yes No
    e. Macular Disease  Yes No
    f. Night Blindness  Yes No
    g. Color Blindness  Yes No
    h. Unexplained Vision Loss  Yes No
    i. Diabetes Mellitus  Yes No
    j. Tumor or Cancer  Yes No
    k. High Blood Pressure  Yes No
    l. Heart Disease  Yes No
    m. Bleeding Disorder  Yes No

    10. If applicable, are you pregnant?

     Yes No

    11. Pleae give the anme, address, and telephone number of your personal medical doctor (not your eye doctor):

    Doctor Name:
    Doctor Phone:
    Doctor Address:

    12. Please give the name, address, and telephone number of the physician that referred you to our office:

    Physician Name:
    Physician Phone:
    Physician Address: