Microsoft word - 1_patient_medical_information_080513

COLUMBUS EYE ASSOCIATES MEDICAL INFORMATION SHEET- (Please answer ALL questions below)
Patient Name:____________________________________________________________ Today's Date:______________ Primary Doctor: _______________________________ Referring Doctor/Clinic: _________________________________ Physicians/Specialists you want us to send correspondence of today’s visit to:___________________________________ _________________________________________________________________________________________________ Please check any medical conditions that you have or are being treated for from the list below: ____ Diabetes(age of onset____) ____ High Cholesterol ____ Multiple Sclerosis ____ Rheumatoid Arthritis ___Meningitis __________________
Females ONLY: Are you currently pregnant? YES or NO. If yes, please give due date: ___________________ Are you currently nursing? YES or NO
Have you ever had an eye or head injury? YES or NO? If yes, specify: _________________________________________________
Have you ever had eye surgery? YES or NO? If yes, list what type of eye surgery/laser and year performed: __________
_________________________________________________________________________________________________
Have you had any general surgeries? (DO NOT include eye surgery) YES or NO? If yes, list______________________
________________________________________________________________________________________________
FAMILY HISTORY: Please circle all of the following that apply to your immediate family (blood relatives):
UNKNOWN | NONE | Alzheimer's | Diabetes | High Blood Pressure | Cancer | Glaucoma
Macular Degeneration | Crossed Eyes | Blindness | Retinal Problems
Are you allergic to any medications? YES or NO? If yes, list the medication you are allergic to and reaction:___________
_________________________________________________________________________________________________
List current EYE Drops (Include ALL over the counter eye drops and eye supplements):____________________________
_________________________________________________________________________________________________________________________
List all of your current medications or provide copy of your current list.(Please include over the counter meds, vitamins
and supplements): _________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
***Have you ever taken Flomax (tamsulosin), Hytrin, or any bladder intolerance medications? YES or NO? *** These
medications may cause an issue with the dilation process of the pupils, even if you are no longer taking them.
Pharmacy: _______________________________ Address:__________________________________Phone#:__________________________ Do you use tobacco products? YES or NO. If yes, what type and how often?_____________________________________________ Do you consume alcohol? YES or NO. If yes, how often?________________________________________________________________ **If you are having a specific problem today with your eyes or vision, please describe the problem on the line provided below and/or check problems from the following list: _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ ____ Visual loss? (sudden or gradual change) ____ Burning sensation in the eyes? ____ Blurred vision at near? ____ Difficulty seeing when working with small

Source: http://www.columbuseyeassociates.com/Patient-Forms/Patient%20Medical%20Information.pdf