Download Eye Diseases - Kosnoski Eye Care

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Primary Care Physician
Name:
Address:
Phone :
Referring Physician
Name:
Address:
Phone :
Health History
What is the main reason
for today’s exam?
When was your last
exam?
Past Surgeries:
Major Illnesses:
Allergy History:
Current Medications:
Eye Diseases
Amblyopia
Blepharitis
Blindness
Cataract(s)
Color Blindness
Diabetic Retinopathy
Dry Eye Syndrome
Eye Injuries
Glaucoma
Glaucoma Suspect
High Risk Medication
Notes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Macular Degeneration
PVD
Retinal Detachment
Strabismus
Other
Additional Notes:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Current Eye Symptoms
Notes
Asthenopic
Glare Sensitivity
Headaches
Light Sensitivity
Tired Eyes
Yes
Yes
Yes
Yes
No
No
No
No
Physiologic
Burning
Dryness
Epiphora
Eyelid Swelling
Eye Pain or Soreness
Foreign Body Sensation
Infection of Eye Lid
Itching
Mucous
Ptosis (Drooping Eyelid)
Redness
Sandy or Gritty Feeling
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Visual Symptoms
Blurred Vision Distance
Blurred Vision Near
Distorted Vision
Double Vision
Flashes of Lights
Floaters or Spots
Fluctuating Vision
Loss of Central Vision
Loss of Side Vision
Loss of Vision
Other
Additional Notes:
Review of Systems – Brief
Last Health Exam: ______________
Yes
No
Constitutional Symptoms (fever, weight loss, etc.)
Yes
No
Ear, Nose Throat, Mouth
Yes
No
Cardiovascular (heart, hypertension, etc.)
Yes
No
Respiratory (asthma, emphysema, etc.)
Yes
No
Gastrointestinal
Yes
No
Genital, Kidney, Bladder
Yes
No
Muscles, Bones, Joints (arthritis, etc.)
Yes
No
Skin (rash, itching, skin cancer, etc.)
Yes
No
Neurological (multiple sclerosis, etc.)
Yes
No
Psychiatric (anxiety, depression, etc.)
Yes
No
Endocrine (diabetic, hypothyroid, etc.)
Yes
No
Blood/Lymph (anemia, cholesterol, etc.)
Yes
No
Allergic/Immunologic (seasonal allergies, lupus, etc.)
Notes
Pregnant
Nursing
Additional Notes:
Yes
Yes
No
No
HbA1C
%
Family History
Eye Diseases
Amblyopia (Lazy Eye)
Blindness
Cataract(s)
Color Blindness
Eye Tumors
Glaucoma
Glaucoma Suspect
Macular Degeneration
Retinal Detachment
Strabismus (Eye Turn)
Other Eye Conditions
Relationship to Patient
Systemic Diseases
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Stroke
Thyroid Disease
Other Diseases
Additional Notes:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Notes
Social History - General
Current
Occupation:
Do you drink alcohol?
Do you smoke?
Years:
No
No
Occasional
Occasional
Past smoker?
Yes
Tobacco use cessation
intervention, counseling?
Yes
No
Do you chew tobacco?
Yes
No
Do you use illegal drugs?
Yes
No
Ethnicity:
No
Employer:
1 per day
1/2 pack / day
2-3 per day
4+ per day
1 pack / day
1+ pack / day
When did you
quit smoking?
Tobacco cessation pharmacologic
therapy?
Do you use nutritional supplements
(vitamins etc.)?
Do you engage in regular exercise?
Marital
Status:
Yes
No
Yes
No
Yes
No
Social History - Vision
Computer Used?
Yes
No
Hours per day:
Distance from computer:
Do you drive?
Yes
No
Daily Mileage:
Do you have visual
difficulty when driving?
Do you have
glare problems?
Yes
No
Do you have any problems with night vision?
No
Since:
Yes
No
Yes
No
Social History - Spectacles
Do you currently
wear glasses?
Yes
Glasses owned
Single Vision
Trifocals
Have you had trouble in the
past with glasses?
Yes
Do you wear sunglasses?
Yes
Special Eyewear Needs
Full Time
Safety Glasses
Progressive
No
Part Time
Distance
Bifocals
Back-up Glasses
Sports Glasses
Other:
If yes, please explain:
Are your sunglasses your current
Yes
No
prescription?
Computer (special prescriptions, special anti-glare tints or coatings)
Safety Glasses (gardening, woodworking, welding)
Occupational (mechanics, plumbers, pilots)
Sports/Hobbies (racquet sports, motorcycle)
No
Hobbies/Interests:
Social History-Contact Lenses
Have you tried to wear contact lenses? Yes
No
Reason for stopping?
If not a contact lens wearer, are you interested in contact lenses at this time?
Do you currently wear contact lenses?
Yes
No
Yes
No
If yes, since:
Type and brand of contact lenses:
How many hours/day?
How many days/week?
Today’s wearing time:
What contact lens solution do you use?
Please rate the following on a scale of 1-10 with 1 being poor and 10 being excellent:
Lens comfort: R:
L:
Distance vision: R:
L:
Near vision: R:
History Reviewed:
No changes
Changes as noted
Close
Initials:
Last History Date:
Date:
L: