Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Ophthalmology Patient Questionnaire
Transcript
Emory Eye Center –New Patient Questionnaire PatientLabelarea PatientName:__________________________________________________Date:_____________________ CurrentAddress:__________________________________________________________________________ CurrentPhone:_________________________DateofBirth:______________________________________ PrimaryCarePhysician:__________________________ReferringPhysician:_________________________ (First&LastName) (First&LastName) PharmacyName:_____________________________________________Phone#:(______)_____________ Pleaseanswerallquestionstothebestofyourabilityandreturnthecompleted questionnairetothetechnicianortechnologistwhenyouarecalled. ReasonforExam(pleaseexplain):_____________________________________________________________ _________________________________________________________________________________________ GeneralHealth(pleasecheck):Excellent PastMedicalHistory Arthritis Asthma Cancer(pleasespecify) Diabetes HeartDisease Hypertension KidneyDisease SkinDisease Stroke NeurologicDisorder Other Yes Good Yearof Diagnosis No Fair Details Poor Emory Eye Center –New Patient Questionnaire PatientLabelarea CURRENTMEDICATIONS Pleaselistallmedicationsyouarecurrentlytaking,orcheck: Nocurrentmedications MedicationName AmountPerDay Reason ALLERGIES Pleaselistallmedicationsorsubstancestowhichyouareallergicandspecifythetypeofreaction,orcheck: Noknownallergies Allergies Reaction Emory Eye Center –New Patient Questionnaire Surgery/Hospitalization PatientLabelarea SURGERYORHOSPITALIZATION Year Details OCULARHISTORY Yes HistoryofEyeInfection,Injury,orSurgery?No Describebriefly:____________________________________________________________________________ __________________________________________________________________________________________ Ifthepatientisachild,youmustcompletethissection.Ifthepatientisanadult,youmayskipthissection. Parent’sName:___________________________________Occupation:______________________________ Parent’sName:___________________________________Occupation:______________________________ Withwhomdoesthepatientlive?____________________________________________________________ Whoisyourchild’spediatrician?Name:________________________________________________________ Address:___________________________________________________________Phone:________________ Werethereanyproblemswithyourchild’sgestation(pregnancy),delivery,orduringthefirst3monthsoflife? No YesIfyes,pleasedescribe:__________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Hasyourchild’sgrowthanddevelopmentbeennormal?Yes No Ifno,pleasedescribe:___________ _________________________________________________________________________________________ _________________________________________________________________________________________ SOCIALHISTORY Smoke:Formersmoker Neversmoker Yes Ifyes,atwhatfrequency?_____________________ Alcohol:None Yes Ifyes,atwhatfrequency?_____________________ Drugs:None Yes Ifyes,pleasedescribe:_______________________ Driving:DrivesintheDaytime DrivesatNight Emory Eye Center –New Patient Questionnaire FamilyHistoryofIllness/Disease PatientLabelarea FAMILYHISTORY Details Relationship OcularDisease Diabetes HeartDisease Hypertension Other(pleaseexplain) REVIEWOFSYSTEMS Pleaseindicateyesornoasdeemedappropriateregardingthefollowingsymptoms. Ifyouarenotsure,pleaseleaveblank NO YES Eyes Comment Blurredvision ________________________________________ Changeinvision ________________________________________ Eyepain ________________________________________ NO YES NO YES NO YES NO YES NO YES Constitutional/Symptoms Changeinweight Changeinactivitylevel Changeingeneralhealth Comment ________________________________________ ________________________________________ ________________________________________ Ear,Nose,Throat&Mouth Hearingproblem Throatsoreness Nasaldrainage Comment ________________________________________ ________________________________________ ________________________________________ Cardiovascular Chestpain Irregularheartbeat Comment ________________________________________ ________________________________________ Respiratory Shortnessofbreath Wheezing Comment ________________________________________ ________________________________________ Gastrointestinal(G.I.) Abdominalpain Diarrhea Constipation Vomiting Comment ________________________________________ ________________________________________ ________________________________________ ________________________________________ Emory Eye Center –New Patient Questionnaire NO YES ol NO YES NO YES NO YES NO YES NO YES NO YES NO YES PatientLabelarea Genitourinary(G.U.) Comment Painordifficultywithurination________________________________________ Bloodordiscolorationinurine________________________________________ Musculoskeletal JointPainorswelling Musclepainorweakness Comment ________________________________________ ________________________________________ Integumentary(Skin) Rash Itching Comment ________________________________________ ________________________________________ Neurological Comment Headache ________________________________________ Dizziness ________________________________________ Weaknessorgaitdisturbance________________________________________ Numbnessortingling ________________________________________ Psychiatric Anxiety Depression Emotionalchanges Inconsolable Comment ________________________________________ ________________________________________ ________________________________________ ________________________________________ Endocrine Comment Changeinsleeporeating ________________________________________ Coldorheatintolerance ________________________________________ Abnormalityingrowthordevelopment________________________________ Hematologic/Lymphatic Comment Frequentbruisingorbleeding________________________________________ Frequentinfections ________________________________________ Allergic/Immunologic Comment Environmentalorfoodallergies________________________________________
