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Transcription:

Name DOB Date Past Medical History Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthryroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation(Irregular Heartbeat) End Stage Renal Disease Leukemia Bone Marrow Transplantation GERD Lymphoma Benign Prostatic Hypertrophy Hearing Loss Prostate Cancer Breast Cancer Hepatitis Radiation Treatment Colon Cancer Hypertension Seizures COPD HIV/AIDS Stroke Other Past Surgical History Appendix(Appendectomy) Bladder(Cystectomy) Joint Replacement Hip RT LT Prostate: Prostate Biopsy Breast: Mastectomy RT LT Kidney: Kidney Biopsy Prostate: TURP Breast: Lumpectomy RT LT Kidney: Nephrectomy Rectum: Low Anterior Resect Breast: Breast Biopsy Kidney Stone Removal Skin: Skin Biopsy Colon: Colon Cancer Recection Kidney Transplant Skin: Basal Cell Carcinoma Colon: Diverticulitis Liver: Shunt Skin: Squamous Cell Carcinom Colon: Inflammatory Bowel Disease Liver: Liver Transplant Skin: Melanoma Colon: Colostomy Liver: Hepatectomy Spleen (Splenectomy) Gallbladder(Cholecystectomy) Ovaries: Endometriosis Testicles (Orchiectomy) Heart: Coronary Artery Bypass Ovaries: Ovarian Cyst Uterus (Hysterectomy): Fibroi Heart: PTCA Ovaries: Ovarian Cancer Uterus (Hysterectomy): Cance Heart: Biological Valve Replacement Ovaries: Tubal Ligation Uterus (Hysterectomy): Cervic Heart: Heart Transplant Pancreas: Pancreatectomy Joint Replacement Knee RT LT Prostate: Prostate Cancer Other: Ocular History Allergic Conjunctivitis Glasses Retinal Tear RT LT Blepharitis Glaucoma Strabismus Cataract RT LT Glaucoma Suspect Vitreous Detachment Contact Lenses Macular Degneration Vitreous Floaters RT LT Corneal Dystrophy RT LT Narrow Angles Other Diabetic Retinopathy Ocular Hypertension Dry Eyes Ophthalmic Migraine Epiretinal Membrane Pseudoexfoliation

Ocular Surgery Blepharoplasty (Eyelid) LASIK/PRK Strabismus Surgery Cataract Surgery RT LT Peripheral Iridotomy YAG Capsulotomy RT LT Corneal Transplant RT LT Ptosis Repair RT LT Other Eye Muscle Surgery Punctal Plugs Glaucoma Surgery Retinal Laser RT LT Intravitreal Injections RT LT Punctal Plugs OCULAR MEDICATIONS Presciption Drops: Prescription Pills or Injections: Over the counter (OTC) Drops: OTC pills/vitamins, etc: Other Medications: Allergies to Medications: Social History Do you Smoke YES NO # packs per day Started smoking Do you drink Acohol YES NO Quit smoking Additional Information # per drink per day Drive in the Daytime Drive at Nighttime Men-65 yrs or older: How many times in the past year hav Not sexually active you had 5 or more drinks in a day Sexually active with one partner Women-65 yrs or older: How may times in the past year h Sexually active with more than one partner you had 4 or more drinks in a day Same sex partner Drug Use IV Drug use How oftern do you exercise? What is your caffeine use? Occupation and Workplace Family History Blindness Cancer Cataracts Diabetes Glaucoma Heart Disease (only first degree relatives, Mother, Father, Sister, Brother, Daughter, Son) Migraine Retinal Detachement Strabismus Stroke Other

Hypertension Macular Degeneration Alerts Allergy to adhesive Allergy to lidocaine Artificial heart valve Artificial joints w/in past two years Blood thinners Defibrillator Flomax use MRSA Narrow angles Pacemaker Premedication prior to procedures Rapid heart beat with Epinephrine Pregnant or planning a pregnancy Pseudoexfoliation syndrome Steroid responder Ebola Risk-travel to country with Ebola or patient contact in past 21 days Ebola Risk-fever, headache or other symptons Review of Systems Poor Vision Elevated Blood Pressure Headache Eye Pain Rapid Heart Beat Seizure Tearing Congestion Stroke Redness Wheezing Paralysis Jaw Pain Shortness of Breath Anxiety Scalp Tenderness Upset Stomach Depression Amaurosis Fugax Diarrhea Insomnia Loss of vision Constipation Uncontrolled Blood Sugar Fever Burning on urination Thyroid abnormalities Chills Urinary Frequency Bleeding Weight Loss Incontinence Anemia Stuffy Nose Joint Pain Allergies Ear Ache Stiffness Hay Fever Cough Arthritis Hives Dry Mouth Rash Other Changing Moles If you are 65 years of age or older, please answer these questions. Vaccination Status Have you received a pneumonia vaccination? Yes No Advance Care Planning Do you have a health care proxy if you are unable to make medical decisions? Yes No If yes, Name Do you have a living will? Yes No Which statement reflects your advance care wishes? Do Not Intubate - I do not wish to have a breathing tube. Do Not Resucitate - I do not wish to have CPR or an automated external defibrillator. Phone Number

Full Cardiopulmonary Resuscitation - All efforts should be made. Name of Pharmacy: Phone # Address: Completed by: Patient Other: Relationship to Patient I attest that the above information is true and correct to the best of my knowledge. Signature: Date:

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