Bring books or toys to help keep your child occupied. I have videotapes in the office that your child may watch.
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- Emily Holmes
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1 USF Eye Institute and Ear, Nose and Throat Center Pediatric Eye Clinic Welcome to the Pediatric Eye Clinic at the University of South Florida! I am glad that your child is coming to visit me at the University for his/her eye care. Here is some information about the clinic and your child's eye exam. EYE EXAM Please feel free to bring records of prior eye exams and surgeries. Please bring a list of your child's medications with you. I usually like to dilate your child's eyes as part of a routine examination. The dilating drops sometimes take a while to work (an hour or more), especially in patients with brown eyes. I have disposable dark glasses in my clinic that an older child (about ages 8 and up) may use when he/she is finished with the exam. For younger children, consider bringing a hat, blanket or dark glasses to wear after the exam is over. Please bring your child's eyeglasses even if he/she does not wear them. Children that wear contact lenses should bring their cases with them. CLINIC My waiting room can sometimes get chilly. Please bring a sweater or jacket. Bring books or toys to help keep your child occupied. I have videotapes in the office that your child may watch. If your child is diabetic, please bring a snack in case his/her blood sugar runs low. For babies, please bring a bottle to the exam. The exam sometimes goes smoother if your baby feeds during the exam. I recommend that you reschedule your child's appointment if he/she is sick. A more accurate exam is usually performed when your child is feeling well. Also, rescheduling your appointment will help to ensure that other children do not become ill due to contact with your child. Dr Nakanishi
2 To: All Patients Provider: Appointment Date and Time: From: Re: USF Eye Institute and Ear, Nose and Throat Center Patient History Forms Attached Please complete and sign the attached forms and bring them with you to your scheduled appointment. **Note**If the appointment is for a minor, a parent or legal guardian must accompany the child and sign the consent to treat a minor in front of a witness at the time of the appointment. If accompanied by other than a parent, we will need to see either the court order stating that you have legal custody or you must bring a notarized letter from the parent stating that you are authorized to accompany the minor and consent to treat, or the minor will not be seen (you must bring this to every office visit and present at the time of check-in). By completing these forms and bringing them with you, you will avoid delays upon your arrival for your scheduled appointment. Thank you in advance for your cooperation. Seena Salyani Administrator, Ophthalmology Karyn Aldridge Administrator, Otolaryngology
3 PLEASE READ: The faculty and staff of the USF Departments of Otolaryngology and Ophthalmology make every effort to make your experience with us as pleasant as possible. To that end, you can assist us by familiarizing yourself with the following: You must have a valid insurance card and a picture ID with you at the time of service. Without these you will not be seen. It is your responsibility to know your insurance benefits. It is not, the responsibility of this office to verify medical eligibility. It is your responsibility to be sure that the faculty of the USF Physician's Group, Departments of either Otolaryngology or Ophthalmology, are providers for your Insurance company prior to making an appointment. It is your responsibility to procure a referral or authorization for the office visit and/or procedure. You must either verify that our office has received your referral/authorization or you must bring it with you to your scheduled appointment. If you do not have a referral or an authorization, or intend to pay cash at the time of service, you will not be seen. Co-payments, co-insurance, deductibles not met, and all past due balances will be collected prior to your visit. If you fail to pay in accordance with your insurance company's contract, you will not be seen. ATTENTION FOSTER PARENTS OR LEGAL GUARDIANS. Foster Parents --you must bring a copy of the court order stating that you have legal custody or the minor will not be seen. You must bring this to every office visit and present at the time of check-in. Legal Guardians - you must bring a NOTARIZED note from the parent stating that you are authorized to accompany the minor and consent to treatment. Unless otherwise stated in note, a new note will be required for every visit, or the minor will not be seen.
4 Dr. Nakanishi BASELINE FORM: CHIEF COMPLAINT/PAST/SOCIAL/FAMILY HISTORY Name of patient: Date: Referring doctor: What is your current eye problem? Have you had any eye problems or surgeries in the past? Yes No If yes, please list: YEAR OPERATION EYE 3. List all medications you take. State frequency and amounts if known: 4. Are you allergic to any medications? Yes No If yes, list: 5. List any surgeries or hospitalizations: YEAR Surgical procedure/reason for YEAR Surgical procedure/reason for hospitalization hospitalization 6. Medical Problems (current or in the past): Yes No Yes No Yes No Diabetes Blood problems Kidney disease Stroke Heart disease Thyroid disease Ulcers Lung disease Asthma Arthritis Liver disease High blood pressure Hepatitis A Hepatitis B Hepatitis C HIV Herpes Simplex Tuberculosis Other: 7. What type of work do you do? 8. Have you ever smoked? Yes No If yes, how many packs per day? How many years? If stopped, date last smoked: 9. Have you ever consumed alcohol? Yes No If yes, how much? If stopped, date last smoked:
5 10. Are you single, married, divorced or widowed? 11. Do you live alone, with someone else, or in a group setting such as a nursing home? 12. Family History: a.) Has anyone in your family had an eye problem? Yes If yes, what kind and who had it? b.) List other diseases in relatives: No 13. Do you NOW have or have you RECENTLY had any of the following symptoms or problems? GENERAL HEALTH Yes No HEAD/EYE/NOSE/ THROAT Yes No HEAD/EYE/NOSE Yes No fever headache dry eyes sudden weight loss head injury drifting eye sudden weight gain scalp tenderness double vision jaundice sinus problems nose bleeds infections eye pain jaw pain night sweats eye infection/redness sore throat swollen lymph nodes eye fatigue neck pain HEART/LUNG Yes No STOMACH INTESTINE Yes No URINARY TRACT Yes No chest pain food allergies blood in urine Irregular heart rate extreme thirst painful urination shortness of breath bleeding in stomach diarrhea/blood in stool ARMS/LEGS/BACK Yes No SKIN Yes No NEUROLOGIC Yes No joint pain rash hallucinations limb weakness/numbness diabetic skin ulcers loss of consciousness trouble lying flat on back dry skin (eczema) depression muscle pain Flushing skin (rosacea) anxiety
6 Additional health information: Signature of person completing this form: Relationship to patient: Self Other Comments of attending physician: Attending physician statement: I have reviewed and confirmed the above information with my changes, as needed: Linda K. Nakanishi, M.D. Date
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
Medical Questionnaire
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