CONFIDENTIAL MEDICAL HISTORY Today’s Date __________________ NAME ________________________________________AGE_________ DATE OF BIRTH_____________________ Referring doctor_____________________________________________ Date of last physical exam _______________ Medical doctor (primary care physician)________________________ Date of last eye exam ____________________ Where do you have your glasses made?________________________ Name of optometrist______________________ Reason for evaluation: ______________________________________________________________________________ Do you currently have any problems in the following areas? If “yes”, provide a description and the doctor who treats you for that problem (if there is one). If there are multiple choices on one line, please circle all that apply. EXPLANATION AND TREATING DOCTOR ________________________________________
Fever………………………….….
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Loss of vision………………………
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Distorted vision (halos)…….………
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Double vision………………………
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Dryness, sandy, or gritty feeling…. ________________________________________ ________________________________________
Redness…………………….………
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Itching, burning, or foreign body sensation.
________________________________________ ________________________________________ ________________________________________
Glare/light sensation……….………
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Post-nasal drip…………………….
________________________________________ ________________________________________
Cardiovascular (heart/blood vessel disease)
________________________________________
Heart attack……………………….
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Ulcer……………………………….
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Joint pain/arthritis………………….
________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________
Stroke………………………………
________________________________________
Psychiatric………………………………….
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Blood problems/bleeding disorder………….
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Sickle cell anemia……….…………
____________________________________________
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____________________________________________
____________________________________________
____________________________________________
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HIV (+) or AIDS……………………………
____________________________________________
Thyroid Disease…………………………
____________________________________________
MALE PATIENTS ONLY:
____________________________________________
Medication used (past or present): Circle all that apply
Flomax (Tamulosin), Rapaflo (Silodosin), Hytrin (Terazosin), Cardura (Doxazosin), Jalyn
PAST HISTORY Please list any allergies to medications or eyedrops____________________________________________________________ Please list all major illnesses and injuries _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Please list any surgeries you have had-include eye surgery _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ FAMILY HISTORY HOW ARE THEY RELATED TO YOU?
Blindness………………………….
__________________________________________________
Cataract…………………………….
__________________________________________________
__________________________________________________
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Diabetes……………………………
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Heart disease……………………….
__________________________________________________
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Stroke………………………………
__________________________________________________
Cancer…………………………….
__________________________________________________
Other……………………………….
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SOCIAL HISTORY CURRENT MEDICATIONS-please list all prescriptions, over-the-counter, medicines AND EYEDROPS (including the dosage and frequency): _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Reprinted from Issue 2 • 2007 Editorial Depo and the God-Doctors Some years ago, my sister declared that the “god-doctor days” were over. She insisted that women are now informed enough to make their own choices and that doctors can no longer expect them to blindly follow the advice they are given. In many instances, that’s true. But Depo-Provera (medroxyprogesterone injecti