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The Zanvyl Krieger Children’s Eye Center at the Wilmer Institute Pediatric Ophthalmology and Adult Strabismus Tel: 410 955-8314 Fax: 410 955-0809 www.wilmer.jhu.edu at The Johns Hopkins Hospital: Wilmer 233, The Johns Hopkins Hospital, Baltimore, MD 21287-9028 at Green Spring Station: 10755 Falls Road, Suite 110, Lutherville, MD 21093 at Columbia: 5900 Cedar Lane, Columbia, MD 21044 Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire Page 1: Background Information As medical doctors as well as eye surgeons, we need to know about more than just the eyes. Please answer all questions to the best of your ability. Note: Some areas apply only to pediatric patients. PLEASE BE SURE TO GIVE A COMPLETE REFERRING PHYSICIAN ADDRESS! Date of first appointment with us: Family Physician (or Pediatrician): Patient's Name: Mailing Address: (Important! We must have an accurate address): Street: City: State: Zip: Home Phone: Home Fax: Phone: Email: Fax: Other Physician(s) not listed above who should receive a report (please give name, specialty, address, and phone): Were you referred to us by your family physician (or pediatrician)? q Yes q No If "no," who referred you, or how did you hear of us? Please indicate above if you prefer that we not send a report to any of the above physicians. This Section For Pediatric Patients: Parents are qMarried qSeparated qDivorced q Living with parent(s) qLiving with relative, guardian, or foster parent Full Name of Father (or Guardian): Full Name of Mother (or Other Guardian) : Family Status - Patient is: Occupation: Occupation: Daytime Phone: Daytime Phone: Other Phone: Email: Fax: Other Phone: Fax: Email: Rev 5/99 dgh Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire Page 2: Occupation and Ocular History Occupation (or school grade if student): If retired, occupation before retiring: If college or graduate student, area of study: Name of employer (or name of school if student): Pediatric patients: List names and ages of brothers and sisters: History of Eye Problems: Yes No Glasses/Contact lenses/Prisms q q q Glasses q Contact lenses q Hard, Gas permeable, or Soft? q Prisms Yes No Other eye symptoms How old is current pair? How old is current pair? Contact lens cleaning solutions: How long? Age or How Long? q q q q q q q q q q q q Diagnosed eye diseases not mentioned above: Eye exam by specialist Patching Eye exercises Eye muscle surgery Other eye surgery Yes No Other eye symptoms q q q q q q q q q q q q Eye injury Stye Recurring “pink eye” Cataract Glaucoma Diabetic eye disease Recent Eye Symptoms: Yes No How long? q q Crossed or wandering eye q q Excessive squinting q q Double vision q q Excessive eye rubbing q q Frequent tearing or discharge q q Blurred vision q q Light sensitivity Other eye symptoms not mentioned above: Yes No q q q q q q q q q q q q q q How long? Drooping eye lid Tired eyes when reading Dry or gritty sensation Itching eyes Red eyes Flashing lights or floaters Poor peripheral vision Age or How Long? Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire Page 3: Recent Symptoms and Family History Other Recent Symptoms: Yes No Symptom q q q q q q q q q q q q q q q q q q q q q q q q How long? Weight loss Excessive fatigue Fever Earaches Sore throat Dry mouth Chest pain Rapid heart rate Shortness of breath Swelling of hands/feet Loss of appetite Vomiting Yes No Symptom q q q q q q q q q q q q q q q q q q q q q q q q Diarrhea/constipation Frequent/painful urination Blood in urine Muscle weakness Rash Headaches Dizziness Numbness Paralysis Memory loss Change in school performance Clumsiness Family History: Which of the patient's relatives have had any of the following? Yes No Eye Conditions in other family members: Which relative? (Circle or fill in.) q q q q q q q q q q q q q q q q q Father Mother Sister Brother Other: q q q q q q q q q q q q q q q q q Glasses before age 6 Amblyopia (“lazy eye”) Patching treatment Strabismus (“crossed” or “wandering” eye) Eye muscle surgery Cataracts in childhood Cataracts Glaucoma in childhood Glaucoma Blindness in childhood Blindness (why?) Eye injury Eye disease caused by diabetes Macular degeneration Retinal detachment Other serious eye disease in childhood Other serious eye disease (describe): Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Yes No Medical conditions in other family members: Which relative (circle or fill in)? q q q q q q q q Father Mother Sister Brother Other: q q q q q q q q Complications from anesthesia Genetic disease (runs in family) Heart disease Diabetes High blood pressure Stroke Cancer Other serious illnesses in family members: Are both parents alive and in good health? Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: Father Mother Sister Brother Other: How long? Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire Page 4: Medical History Medical History Yes No Condition Yes No Condition q q q q q q q q q q q q q q q q q q q q q q q q Frequent ear infections Sinus disease Heart disease High blood pressure Asthma Other lung disease Arthritis Thyroid problem q q q q q q q q Diabetes Anemia Kidney disease Neurologic disease Seizures or stroke Depression Cancer Missing immunizations Major illnesses not mentioned above (other than eye problems): Previous surgery or other hospitalizations: Medications List any eye drops the patient is taking: q NONE Eye drop and frequency Why is this medication being used? List any medications the patient is taking: q NONE Medication and dosage (if known) Why is this medication being used? List any known allergies to medications: q NONE Medication Reaction Birth history (Pediatric patients only): Birth weight: ____ lb, ____ oz Yes No Condition Please provide details q q q q q q q Describe: Describe: q q q q q q q Problems during pregnancy Problems during delivery Forceps delivery Cesarean section Delivered early or late Baby kept in hospital due to illness Delayed development How many weeks? Why and how long? Describe: Reviewed by: Dr. ________________