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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________________________________________
