Health History Form Please Fill Out Entire Form
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3 Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision Burning/Dryness Double Vision Excess Tearing/Watering Loss of Vision Loss of Side Vision Pain or Soreness Redness Itching/Scratching Seeing at a Distance Glare/Light Sensitivity Reading In General Eye History: Date Diagnosed Date Surgery Date Diagnosed Date Surgery Cataract Retina Problem Glaucoma Eyelid Eye Muscle Refractive Other Current Eye Medications: Current Medications and Usage: Over the Counter Medication: Allergies to Medicines: Height: Weight: Surgical History (with dates): Family History (Check those that Apply and Write the Relationship to you) Cataract Glaucoma Macular Degeneration Blindness Cancer Diabetes Cardiovascular Disease Stroke Other Major Illness or Hereditary Disorder Turn over --->
4 Medical History: Check all that apply Constitutional Systems Fever Weight Loss/Weight Gain Trouble Sleeping/Insomnia Cardiovascular Congestive Heart Failure Heart Attack/Coronary Stent Arrhythmia (AFib, tachy, etc) High Blood Pressure Elevated Cholesterol History of Bypass Surgery Pacemaker/ICD Ears, Nose, Mouth, Throat Hearing Problems/Tinnitus Sinus Congestion Respiratory Emphysema Asthma Lung Cancer Sleep Apnea COPD Chronic Cough/Bronchitis Oxygen Use Neurological Migraines/Headaches Seizures/Epilepsy Stroke Multiple Sclerosis Parkinson s Disease Alzheimer s/dementia Vertigo Gastrointestinal Psychiatric Hepatitis Depression/Bipolar Ulcers/Bleeding Anxiety Stomach/Bowel Cancer PTSD G.E.R.D/Acid Reflux Schizophrenia Genitourinary Enlarged Prostate/Prostate Cancer Cervical/Ovarian/Uterine Cancer Kidney Disease Overactive Bladder Currently Pregnant Musculoskeletal Osteopenia/Osteoporosis Degenerative (Osteo) Arthritis Gout Bell s Palsy Fibromyalgia Integumentary Shingles Skin Cancer Eczema/Psoriasis Hematologic/Lymphatic Anemia/Sickle Cell Hemophilia Leukemia Lymphoma Lyme Disease Mentally Disabled Endocrine Type 1 Diabetes Type 2 Diabetes Hypothyroidism Hyperthyroidism Breast Cancer Allergic/Immunologic Seasonal Allergies/Hay Fever Rheumatoid Arthritis Sjogren s (dry eye/mouth) Lupus HIV Other Immune Disorder Social History Latest Hgb/A1c Alcohol Everyday Occasional None Tobacco Heavy Light Chew Never Former Drugs Marijuana Other None Exercise Yes No Explanation of Other Diagnosed Medical Condition Not Listed: Date: Signature:
5 Refractive Surgery Questionnaire Please Fill Out Entire Form Which do you currently wear?: Check all that apply Glasses Bifocals Toric Contacts (soft) Soft Contacts Reading Glasses Only Rigid Contacts (RGPs) Multifocal Contacts Extended Contacts (sleep in them) Monovision Contacts (one eye for near and one for distance) Progressive Glasses (no line bifocals) How long have you worn corrective lenses (glasses or contacts)? Why are you interested in having laser vision correction? What type of work do you do (occupation)? How much time do you spend on close up tasks like reading, sewing or computer use? A Little Moderate Amount A Lot Do you participate in any contact sports or combat sports (boxing, MMA, football, etc)? How did you hear about laser vision correction at Skyline Vision Clinic & Laser Center? If you were referred to Skyline by another doctor, please list their name here: Are you taking any of the following medications right now? Amiodarone Immitrex (Sumatriptan) Accutane (Isotretinoin) Do you have any symptoms of dry eye (burning, stinging, gritty sensation, tearing)? Do you use artificial tears (moisturizing drops) or any medications specifically for dry eyes (Restasis, Xiidra, etc)? Do you have any of the following medical conditions? Pregnant or Nursing Shingles of the Eye Herpetic Eye Disease (infection by herpes virus, also known as HSV) Any Autoimmune or Inflammatory Disease (rheumatoid arthritis, lupus, Sjogren s syndrome, scleroderma, inflammatory bowel disease, etc) History of excess scar formation (keloids) Have your glasses or contact lens prescription changed within the last year?
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP