Download Do you currently have any of the following problems?

PERSONAL HISTORY (ROS) - Do you currently have any of the following problems?
System
Yes or No Date diagnosed
Eye disease, eye injury, eye surgery
Constitutional (fever, weight loss, other)
Ears (reduced hearing or hearing loss)
Nose/Mouth/Throat (sinus problems, sore throat)
Cardiovascular (heart, blood vessels), hypertension
Respiratory (breathing problems, lungs, cough)
Gastrointestinal (heartburn, diarrhea, vomiting, GERD, acid reflux)
Neurological (numbness, weakness, stroke, headaches, paralysis,)
Females – Pregnant? / Nursing?
Genitourinary (reproductive organ problems, urinary problems, kidneys)
Cancer (List Type)
Dermatologic (skin)
Musculoskeletal (muscle or joint problems)
Rheumatological (Rheumatoid Arthritis, Lupus, Sarcoidosis, gout, etc.)
Diabetes
Allergic/Immunologic
Psychiatric (depression)
Hematologic (bleeding tendency, anemia)
Any other health issues
Do you Use tobacco, alcohol or drugs?
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
Please describe
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
Please list all medications you take (we will copy your prepared list if you wish)
Name of Medication Taken for what condition
Dosage
Frequency Name of Medication Taken for what condition
Dosage
Frequency
Please list all major illnesses or surgeries you have had (we will copy your prepared list if you wish)
Procedure / Diagnosis
Reason
Date
Family History
*
*
*
Glaucoma
Cataracts
Stroke
*
*
*
Diabetes
Heart Disease
Hypertension
*
*
*
*
Amblyopia (Lazy Eye)
Macular Degeneration
Retinal Detachment
Strabismus (Eye turn)
Please list who has these problems:
Visual Function
Are you satisfied with your current vision?
Do you wear glasses?
Do you wear computer glasses?
Do you wear prescription sunglasses?
Do you wear non-prescription sunglasses?
Do you wear safety or sport goggles?
Do you wear contact lenses?
Are you experiencing any difficulty with the following?
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*N
*N
*N
*N
*N
*N
*N
What solutions do you use?
Reading a newspaper or book
Working on the computer
Recognizing people when close
Seeing steps, stairs, or curbs
Bothered by glare/halos
Difficulty driving on bright sunny days
Difficulty driving at night
What brand or type of lenses do you wear?
Are you interested in laser vision correction? * Y
Reading small print
Reading traffic signs, street signs
*N
Doing fine handiwork
Writing checks, completing forms
Playing games (i.e. bingo, cards)
Participating in sports
Cooking/Hobbies
Watching TV
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*Y
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N
*N