MEDICAL HISTORY QUESTIONNAIRE

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Shannon Bennett
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1 MEDICAL HISTORY QUESTIONNAIRE Name Birth Date Name of doctor referring you Doctor Phone Doctor Address Date of last eye exam REVIEW OF SYSTEMS Do you currently have any problems in the following areas? If "yes," provide information. YES NO EXPLANATION OF PROBLEM Integument (skin) Head Headaches Migraines Eyes Loss of vision Blurred vision Distorted vision (halos) Loss of side vision Double vision Dryness Mucous discharge Redness Itching/Burning Foreign body sensation Excess tearing/watering Glare/Light sensitivity Eye pain or soreness Infection of eye or lid Do you have visual difficulty when driving? Do you have problem with night vision? Do you currently wear contact lenses? Do you currently wear glasses? Ears, nose, mouth, throat Any problems Respiratory (lungs/breathing) Cardiovascular (heart/blood vessels) Gastrointestinal (stomach/intestines) Genitourinary (genitals/kidney/bladder) Bones, joints, muscles Neurological system Lymphatics (lymph nodes/swelling) Hematopoletic (blood) Allergic/Immunologic Seasonal allergies Hay fever symptoms Psychiatric RS-103A

2 Do you currently have any problems in the following areas? If "yes," provide information. YES NO EXPLANATION OF PROBLEM A Persistant Cough (one that has lasted for 3 or more weeks) Bloody Sputum Night Sweats Weight Loss Anorexia Fever PAST HISTORY List any medications you take List all major illnesses and injuries List any non-eye surgeries you have had in the past List all recent hospitalizations with explanations of what they were for Have you had crossed eyes, lazy eye, drooping eyelid, prominent eyes, previous contact lens wearer? Do you have allergies to any medications? YES NO If YES, list medications FAMILY HISTORY What is the health status or cause of death of your parents, siblings or children? DISEASE YES NO RELATIONSHIP TO PATIENT Blindness Cataract Glaucoma Macular degeneration Retinal detachment Cancer Diabetes Heart attacks High blood pressure Kidney disease Other SOCIAL HISTORY Marital Status Single Married Divorced Widowed o Other Current occupation Do you drive? YES NO Do you drink alcohol? YES NO If YES, how many glasses a day? Do you smoke? YES NO If YES, how many packs a day? Any history of venereal disease? YES NO Are you H.I.V. positive YES NO History reviewed. Physician's signature: Date: RS-103B

3 PATIENT REGISTRATION FORM Male / Female First Name MI Last Name Marital Status Address Street City, State Zip Code Social Security # - - Date of Birth: Age Home #: Work #: Cell #: address: Race/Ethnicity: Referring Doctor: Family Doctor: Employer/Occupation Employer Address: Emergency Contact Information Name: Relationship: Phone: Name: Relationship: Phone: Medical Insurance Information Insurance Company: Subscriber s Name Subscriber s SSN: Subscriber s Date of Birth Subscriber s Employer: Relationship to Subscriber: **Please complete the following if patient is a minor** Father s Name: Work # Cell # Mother s Name: Work # Cell # Father s Occupation Mother s Occupation Signature: Date: Signature Authorization I, the undersigned, assign directly to Retina Consultants, PC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. Patient Signature Date 07/09/14 el

5 Marion Joseph Stoj, M.D. Jerry Neuwirth, M.D. Peter H. Judson, M.D. Michael S. Ruddat, M.D. Andrew J. Packer, M.D. Ron Margolis, M.D. RC Seymour Street, Suite 822 Hartford, CT Phone: (860) Fax: (860) Woodland Street, Suite 100 Hartford, CT Phone: (860) Fax: (860) Main Street Manchester, CT Phone: (860) Fax: (860) Farmington Ave. Farmington, CT Phone: (860) Fax: (860) Cranbrook Blvd., First Floor Enfield, CT Phone: (860) Fax: (860) Shunpike Road, Suite 103 Cromwell, CT Phone: (860) Fax: (860)

7 Name: Date: Information Source: h Patient h Spouse h Parent h Medication List h H & P h Rx Containers h Currently takes no medications h Unable to obtain medication history Allergies Reaction Allergies Reaction List all Home Medications (Prescriptions, Over the Counter, Herbals, Patches, Inhalers, Eye Drops and Supplements) Drug Name Dose Route Frequency

Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address:

Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address: Medical History Form Patient Information Salutation: Sex: Current Address: Email: Employer: First Name: Last Name: Middle Initial: Date: City: Zip Code: Phone 1: Phone 2: Date of Birth: Referral Source: