New Patient History Name:First Name*Last Name*MI*Section BreakSection Break1. Do you have, or have you ever had:a. Diabetes Mellitus:YesNoDiabetes Mellitus: Date of Onset and/or DetailsTreatment: Diet Control Oral Agents Insulin b. Medical Complications: Renal Neuropathy Vascular Other Medical Complications: Date of Onset and/or Detailsc. Heart AttackYesNoHeart Attack: Date of Onset and/or DetailsAngina or Chest PainYesNoAngina or Chest Pain: Date of Onset and/or DetailsHeart FailureYesNoHeart Failure: Date of Onset and/or DetailsIrregular or Rapid HeartbeatYesNoIrregular or Rapid Heartbeat: Date of Onset and/or DetailsCardiac Pacemaker InsertedYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsd. High Blood PressureYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailse. A Stroke or “Shock”YesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsf. AnemiaYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsg. AsthmaYesNoCardiac Pacemaker Inserted: Date of Onset and/or DetailsEmphysema and/or BronchitisYesNoCardiac Pacemaker Inserted: Date of Onset and/or DetailsPneumoniaYesNoCardiac Pacemaker Inserted: Date of Onset and/or DetailsTuberculosisYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsh. Liver Disease or JaundiceYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsi. Stomach or Duodenal UlcerYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsj. Kidney Stones or Other DiseaseYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsk. Arthritis (if yes, type)YesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsl. Cancer or TumorYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsm. Thyroid DiseaseYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsn. Seizures or Nervous BreakdownYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailso. Varicose Veins / Blood Clots in LegsYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsp. Bleeding DisordersYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsq. Transfusions of Blood or PlasmaYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailsr. TAIDS, ARC, or HIV Positive TestYesNoCardiac Pacemaker Inserted: Date of Onset and/or Detailss. Other Medical ProblemsYesNoCardiac Pacemaker Inserted: Date of Onset and/or DetailsSection BreakHave you traveled to West African countries: Guinea, Nigeria, Sierra Leone, Liberia, Sengal, or Democratic Republic of the Congo in the past 21 days?YesNoHave you been in physical contact or cared for anyone with diagnosed or suspected to have Ebola virus disease?YesNoHave you had a fever ( > 100.4 F) plus any one of the following symptoms: diarrhea, vomiting, headache, weakness, muscle pain, abdominal pain, or hemorrhaging?YesNoSection Break2. Are you allergic to any medications or to any foods?YesNoIf yes, please describe the substance(s), with date and type of reaction:allergic to any medications or to any foodsSection Break3. What other medications do you take regularly?When did you last use aspirin, in any form?Section Break4. Have you had any previous eye surgery/laser, or injuries?YesNoSection Break5. What non-ocular operations have you had? Please give type(s) and date(s):Section Break6. Are you a smoker?YesNoIf yes, how many cigarettes per day?If no, and you smoked in the past, when did you stop?Section Break7. Substance AbuseAlcohol?YesNoAlcohol AbuseModerateDailyDrug Abuse?YesNoSection Break8. Have you gained or lost more than ten pounds in the past year?YesNoIf yes, how many pounds have you gained?or lost?Please Explain:Section Break9. Among blood relatives, is there a history of any of the following:a. GlaucomaYesNob. CataractsYesNoc. "Lazy Eye" or Muscle ImbalanceYesNod. Retinal DiseaseYesNoe. Macular DiseaseYesNof. Night BlindnessYesNog. Color BlindnessYesNoh. Unexplained Vision LossYesNoi. Diabetes MellitusYesNoj. Tumor or CancerYesNok. High Blood PressureYesNol. Heart DiseaseYesNom. Bleeding DisorderYesNoSection Break10. If applicable, are you pregnant?YesNoSection Break11. Pleae give the anme, address, and telephone number of your personal medical doctor (not your eye doctor):Doctor Name:Doctor Phone:Doctor Address:Section Break12. Please give the name, address, and telephone number of the physician that referred you to our office:Physician Name:Physician Phone:Physician Address: This iframe contains the logic required to handle Ajax powered Gravity Forms.
