New medical history form 10:19:10

CENTURY EYE CARE MEDICAL HISTORY QUESTIONNAIRE
REFERRING DR.
List all medications(you may use the back of this sheet): ☐ None Allergies to medications: ☐ None
List all medical conditions: ☐ None
SYMPTOMS
☐ Yes ☐ No Recent vision loss ☐Yes ☐ No Floaters☐ Yes ☐ No Flashes of light ☐Yes ☐ No Loss of peripheral vision☐ Yes ☐ No Night time glare ☐Yes ☐ No Tired eyes ☐ Yes ☐ No Double vision ☐Yes ☐ No Dryness ☐ Yes ☐ No Tearing ☐Yes ☐ No Eye discharge☐ Yes ☐ No Redness ☐Yes ☐ No Sandy/gritty feeling☐ Yes ☐ No Itching ☐Yes ☐ No Eye pain/ burning☐ Yes ☐ No Foreign body sensation ☐Yes ☐ No Eyelid swelling Please use this space to explain further:__________________________________________________________________________ GENERAL MEDICAL REVIEW(explain further in space provided)
☐Yes ☐ No Fever________________________________
☐Yes ☐ No Weight loss
☐Yes ☐ No Ears/Nose/Throat (sinus,ear infections,chronic cough,dry mouth.)________________________________________
☐Yes ☐ No Cardiovascular (heart, vessels etc)_________________________________________________________________
☐Yes ☐ No Respiratory (Asthma,emphysema,etc.)______________________________________________________________
☐Yes ☐ No Gastrointestinal (Stomach ulcers,intestinal disease, etc.)________________________________________________
☐Yes ☐ No Genital, Kidney, Bladder, Prostate__________________________________________________________________
☐Yes ☐ No Muscle, Bone, Joints____________________________________________________________________________
☐Yes ☐ No Skin (acne, warts, skin cancer, etc)_________________________________________________________________
☐Yes ☐ No Neurological (multiple sclerosis, strokes, brain tumors, etc)______________________________________________
☐Yes ☐ No Psychiatric (depression, anxiety, ADHD, etc)_________________________________________________________
☐Yes ☐ No Endocrine (diabetes, thyroid, etc)__________________________________________________________________
☐Yes ☐ No Blood/Lymphatics_______________________________________________________________________________
☐Yes ☐ No Have you ever taken Flomax?
☐Yes ☐ No Do you take blood thinners(Aspirin, Coumadin, Plavix, Vitamin E)?
FAMILY HISTORY(write relation next to illness)
☐ Blindness___________ ☐ Retinal detachment_____________ P: Parents
☐ Glaucoma__________ ☐ Macular degeneration____________ S: Siblings
☐ Diabetes__________ ☐ Heart disease or high blood pressure__________ GP: Grandparents
CH: Children
Kidney disease__________ ☐ Lupus___________ AU: Aunt or Uncle
☐ Stroke__________ ☐ Thyroid disease____________ CO: Cousin
SOCIAL INFORMATION
☐ Retired ☐ Student Occupation:_______________________________
Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widow ☐ Lives alone ☐ With_________________________
Do you drive? ☐ Yes ☐ No
Do you wear contacts? ☐ Yes ☐ No
How often do you drink alcohol? ☐ Never ☐ Occasionally ☐ Once daily ☐ 2-3 per day ☐ 4+ per day
Do you smoke? ☐ Never ☐ Occasionally ☐ 1/2 pack daily ☐ 1 pack daily ☐ > 1 pack daily

THIS SECTION FOR STAFF ONLY
Phys. Sig:________________ T
ys. Sig:_____________________________Date:_________ Phys. Sig:__________________________Date:__________ Phys. Sig:_____________________________Date:_________

Source: http://www.centuryeye.com/pdf/Medical_History.pdf