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Download OCULAR HISTORY - Dr. Steven Wilkins Optometrist
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PATIENT HISTORY Patient Name: _________________________________________________________Date: _____________ Primary Care Physician: ____________________________________________________________________ PAST MEDICAL HISTORY Select any of the following medical conditions that you currently have: Alzheimer’s Disease Anemia Anxiety Arthritis Asthma Atrial Fibrillation (Irregular Heartbeat) Bells Palsy Benign Prostate Hyperplasia Bone Marrow Transplantation Breast Cancer Bronchitis Colon Cancer COPD Coronary Artery Disease Dementia Depression Diabetes Emphysema End Stage Renal Disease GERD Hearing Loss Hepatitis Herpes HIV/AIDS Hypercholesterolemia Hypertension Hyperthyroidism Leukemia Lung Cancer Lupus Lymphoma Multiple Sclerosis Osteoporosis Prostate Cancer Radiation Treatment Sarcoidosis Seizures Sickle Cell/Trait Stroke Weight Loss/Gain OTHER: Have you had any surgeries on the following organs? Appendix (appendectomy) Bladder (cystectomy) Breast Colon Gallbladder Heart Joint Replacement: Hip Joint Replacement: Knee Joint Replacement: Shoulder Kidney OTHER: Liver Ovaries Pancreas Prostate Rectum Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Spleen Uterus (Hysterctomy) OCULAR HISTORY OCULAR HISTORY Select any of the following that apply to you: Allergic Conjunctivitis Blepharitis Cataract Right Eye Cataract Left Eye Contact Lenses Corneal Dystrophy Right Eye Corneal Dystrophy Left Eye Diabetic Retinopathy, Background Right Eye Diabetic Retinopathy, Background Left Eye Diabetic Retinopathy, Proliferative Right Eye Diabetic Retinopathy, Proliferative Left Eye Dry Eye Glasses Glaucoma Right Eye Glaucoma Left Eye Macular Degeneration Right Eye Macular Degeneration Left Eye Narrow Angles Right Eye Narrow Angles Left Eye Ocular Hypertension Right Eye Ocular Hypertension Left Eye Ophthalmic Migraine Pseudoexfoliation Retinal Tear Right Eye Retinal Tear Left Eye Strabismus Post Vitreous Detachment Right Eye Post Vitreous Detachment Left Eye Vitreous Floaters Right Eye Vitreous Floaters Left Eye OTHER: OCULAR SURGERY Blepharoplasty Right Eye Blepharoplasty Left Eye Cataract Surgery Right Eye Cataract Surgery Left Eye Corneal Transplant Right Eye Corneal Transplant Left Eye DSAEK Right Eye DSAEK Left Eye Eye Muscle Surgery Intravitreal Injections Right Eye Intravitreal Injections Left Eye LASIK Right Eye LASIK Left Eye LPI (laser peripheral iridotomy) Right Eye LPI (laser peripheral iridotomy) Left Eye LTP(laser trabeculoplasty ) Right Eye LTP(laser trabeculoplasty ) Left Eye OTHER: PRK Right Eye PRK Left Eye Ptosis Repair Right Eye Ptosis Repair Left Eye Punctal Plugs Right Eye Puntal Plugs Left Eye Strabismus Surgery Retinal Laser Surgery Right Eye Retinal Laser Surgery Left Eye Trabeculectomy Right Eye Trabeculectomy Left Eye Tube Shunt Right Eye Tube Shunt Left Eye Yag Capsulotomy Right Eye Yag Capsulotomy Left Eye MEDICATIONS None Please list all medications: Name Dosage DRUG ALLERGIES None Please list all known Drug Allergies: SOCIAL HISTORY Please Check Smoking Status Current everyday smoker Current some day smoker (tobacco) Current some day smoker (cigarette) Former smoker Never smoked Cigar Smoker Heavy tobacco smoker Light tobacco smoker Number of packs per day Date Started Smoking ILLEGAL DRUG USE None How Often? SOCIAL HISTORY DETAILS Please Check ALCOHOL USE None Less than 1 drink per day 1-2 Drinks per day 3 or more drinks per day SAFETY Patient feels safe at home Patient feels unsafe at home DRIVING STATUS Drives in the Daytime Drives at Night EXERCISE – How often do you exercise? Several times a day Once a day A few times a week A few times a month Never CAFFEINE USE Several times a day Once a day A few times a week A few times a month Never OCCUPATION AND WORKPLACE: PLACE OF RESIDENCE: Date Quit Smoking Total Years Smoking REVIEW OF SYSTEMS Please Check all that apply NAME Poor vision Eye pain Tearing Redness Jaw pain Scalp tenderness Amaurosis fugax Loss of vision Fever Chills Weight Loss Stuffy Nose Ear ache Cough Dry mouth High blood pressure Rapid heart beat Congestion Wheezing Shortness of breath Upset stomach Diarrhea Constipation Burning on urination Urinary frequency Incontinence Joint pains Stiffness Arthritis Rash Changing moles Headache Seizure Stroke Paralysis Anxiety Depression Insomnia Diabetes Thyroid abnormalities Bleeding Anemia Allergies Hay fever Hives REVIEW OF SYSTEMS CONTINUED Please Check all that apply Allergy to Adhesive Allergy to Lidocaine Artificial Heart Valve Artificial Joints within past two years Blood Thinners Defibrillator Flomax MRSA Narrow Angles Pacemaker Premedication prior to procedures Rapid heart beat with epinephrine Pregnancy or planning a pregnancy Pseudoexfoliation syndrome Steroid responder West Africa: Travel or Contact EBOLA Risk: Fever > 100.4 degrees (F) / 38.0 degrees (c) EBOLA Risk: Resided or Traveled to Country with wide-spread EBOLA transmission in the last 21 days EBOLA Risk: Contact with an EBOLA Patient without proper equipment in the last 21 days EBOLA Risk: Headaches, weakness, muscle pain, vomiting, diarrhea, abdominal pain and/or hemorrhage FAMILY HISTORY Do you have any family members with any ocular disease? Please check all that apply Ocular Disease Family Member Cataract Glaucoma Crossing Eyes Macular Degeneration Retinal Disease Other: Do you have any family members with any systemic disease: Please check all that apply Systemic Disease Family Member Cancer Diabetes Heart Disease/Stroke High Blood Pressure High Cholesterol Other: Are you currently pregnant? _____yes Due Date: ___________ _____no
