HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**

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Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes If yes, AIC Sugar Who is your primary physician treating your diabetes? End Stage Renal Disease GERD / REFLUX Hearing Loss Hepatitis High Blood Pressure If yes, last blood pressure reading / HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Other Please list PAST SURGICAL HISTORY: Appendix Removed Bladder Removed Breast: Biopsy, Lumpectomy, Mastectomy Colon: Cancer, Diverticulitis, Colostomy Gallbladder Removed Heart: Valve replacement Heart: Coronary Artery Bypass Heart: PTCA Heart Transplant Joint Replacement, Knee Right / Left Joint Replacement, Hip Right / Left Kidney: Biopsy, Stone Remove, Transplant Liver: Shunt, Transplant, Hepatectomy Ovaries: Endometriosis, Cancer, Cyst, Tubal Pancreas: Pancreatectomy Prostate: Biopsy, Cancer, TURP Rectum: APR, Resection Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed Right / Left/ Both Hysterectomy: Fibroids, Cancer C- Section Valve Replacement OTHER- Please list PHARMACY: (location) 1

MEDICATIONS: If you have a medication list, we can make a copy for our records. EYE DROPS: Glaucoma drops: Artificial tear: Other: ALERTS: Do you have or have you ever had one of the following? Blood Thinners Artificial Heart Valve Defibrillator Pacemaker MRSA ALLERGIES: (circle all that apply) REACTION No Known Drug Allergy NKDA SEVERITY Sulfa MILD MODERATE- SEVERE Codeine MILD MODERATE- SEVERE Penicillin MILD MODERATE- SEVERE Adhesive MILD MODERATE- SEVERE Lidocaine MILD MODERATE- SEVERE OTHER: MILD MODERATE- SEVERE MILD MODERATE- SEVERE MILD MODERATE- SEVERE 2

SOCIAL HISTORY: Cigarette Smoking: Never smoked Former Smoker Current Smoker **CIRCLE ALL THAT APPLY** Alcohol Use: None Social (less than 1 a day) 1-2 Drinks a day 3 or more Drinks a day FAMILY HISTORY: PARENTS, GRANDPARENTS, SIBLINGS, AUNTS, UNCLES Glaucoma Macular degeneration Retinal detachment Diabetes Stroke Heart disease Cancer Thyroid Arthritis Other: REVIEW OF SYSTEMS: **CIRCLE ALL THAT APPLY** -----some may be the same as medical history----- EYES: ENDOCRINE: RESPIRATORY: CARDIOVASCULAR: CONSTITUTIONAL: NEUROLOGICAL: MUSCULOSKELETAL: PSYCHIATRIC: ENT/ MOUTH: GASTROINTESTINAL: GENITOURINARY: INTEFUMENTARY: HEMATOLOGIC: IMMUNOLOGIC: Change in vision, Pain, Tearing, Redness, Jaw Pain, Scalp Tenderness, Sudden vision loss Diabetes, Thyroid Shortness of breath, Congestion, Wheezing High Blood Pressure, Cough, Rapid Heart Beat Sudden Weight Loss, Fever, Chills Headaches, Seizure, Stroke, Paralysis Arthritis, Joint Pain, Stiffness Anxiety, Depression, Insomnia Stuffy nose, Earache, Dry mouth Upset stomach, Diarrhea, Constipation, Burning Urination, Urinary Frequency, Incontinence Rash, Changing Moles Anemia, Bleeding Hay fever, Hives 3

**CIRCLE ALL THAT APPLY** OCULAR HISTORY: Allergic Conjunctivitis Amblyopic (Lazy Eye) Blepharitis Cataract Right/ Left Contact Lens Corneal Dystrophy Right/ Left Diabetic Retinopathy (background) Right/ Left Diabetic Retinopathy (proliferative) Right/ Left Dry Eyes Glasses Glaucoma -- Right/ Left Macular Degeneration Right/ Left Macular ERM Right/ Left Narrow Angles Right/ Left Ocular Hypertension Right/ Left Ocular Migraine Foreign Body Removal Retinal Tear Right/ Left Strabismus PVD Right/ Left Vitreous Floaters Right/ Left Other: OCULAR SURGERY: Blepharoplasty Right/ Left Cataract Surgery Right/ Left Corneal Transplant Right /Left DSAEK Right/ Left Eye Muscle Surgery Intravitreal Injections Right/ Left LASIK Right/ Left LPI Right/ Left LTP Right / Left PRK Right/ Left Ptosis Repair Right/ Left Punctal Plugs Right/ Left Strabismus Surgery Retinal Laser Right / Left Trabeculectomy Right/ Left Tube Shunt Right/ Left YAG Capsulotomy Right/ Left Other: 4

GADDY EYE CLINIC PATIENT INFORMATION SHEET Last Name: Marital Status: First Name: Employer: Middle Initial: Suffix: Sex: Email: Phone: Work Phone: Soc. Sec. # Race: Language: Date of Birth: Age: Ethnicity: (please circle) Hispanic / Non-Hispanic Street Address: City, State, Zip: INSURANCE INFORMATION: Primary Insurance: Policy Holder s Name: Policy Number: Policy Holder s SSN#: Policy Holder s DOB: Policy Holder s Employer: Secondary Insurance: Policy Holder s Name: Policy Number: Policy Holder s SSN#: Policy Holder s DOB: Policy Holder s Employer: In Case of Emergency: Phone: SIGNATURE ON FILE: I authorize payment benefits to be made payable to Dr. Gene Gaddy. My authorization is hereby given to Dr. Gene Gaddy to submit any claims to my insurance carrier in my behalf. I understand that I am responsible for deductible amount and the percent that my insurance does not cover. Policy Holder/Patient Date 5

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