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WELLISH VISION INSTITUTE KENT L. WELLISH, M.D. RICHARD L. RELYEA, M.D. YOUR NAME:________________________________ TODAY’S DATE:___________________________ WHO REQUESTED YOU BE SEEN IN OUR CLINIC?___________________________________________ WHO IS YOUR GENERAL MEDICAL DOCTOR?______________________________________________ WHY ARE YOU BEING SEEN TODAY? (DESCRIBE YOUR EYE PROBLEM): _____________________________________________________________________________________________ PLEASE CIRCLE ANY OF THE FOLLOWING MEDICAL PROBLEMS YOU HAVE EXPERIENCED STROKE HEADACHES WEAKNESS DEPRESSION HEARING LOSS YES YES YES YES YES NO NO NO NO NO HEART ATTACK RHYTHM PROBLEM HEART FAILURE HIGH BLOOD PRESSURE HEART MURMUR YES YES YES YES YES NO NO NO NO NO SHORTNESS OF BRTH ASTHMA EMPHYSEMA/COPD ALLEGRIES/HAY FEVER YES YES YES YES NO NO NO NO DIABETES THYROID PROBLEMS WEIGHT LOSS CANCER YES YES YES YES NO NO NO NO HIV/AIDS HEPATITIS SHINGLES HERPES/COLD SORES YES YES YES YES NO NO NO NO ARTHRITIS BLEEDING DISORDER YES YES NO NO KIDNEY PROBLEMS BLADDER PROBLEMS YES YES NO NO CHRONIC DIARRHEA CHRONIC CONSTIPATION ULCERS SKIN RASHES YES YES YES YES NO NO NO NO PLEASE LIST ANY PAST SURGERIES _______________________________ _______________________________ ___________________________ _______________________________ _______________________________ ___________________________ PLEASE CIRCLE ANY OF THE FOLLOWING EYE CONDITIONS YOU HAVE EXPERIENCED RETINAL DETACHMENT GLAUCOMA GLAUCOMA SURGERY CATARACTS MACULAR DEGENERATION REFRACTIVE SURGERY LASER SURGERY YES YES YES YES YES YES YES NO NO NO NO NO NO NO RETINAL SURGERY DRY EYE EYE INJURIES STIES/CHALZAIONS CATARACT SURGERY LAZY EYE CROSSED EYES Last printed 5/19/2005 3:16:00 PM YES YES YES YES YES YES YES NO NO NO NO NO NO NO DO YOU HAVE ANY OF THE FOLLOWING EYE SYMPTOMS BURNING SANDY/GRITTY MUCOUS DISCHARGE TIRED EYES YES YES YES YES NO NO NO NO REDNESS ITCHING CONTACT LENS DISCHARGE YES YES YES DO YOU USE ARTIFICIAL TEARS YES NO WHAT BRAND?_____________________________ DO YOU WEAR CONTACT LENSES? YES HOW LONG?________________________________ NO DO YOU WEAR GLASSES? YES NO HOW LONG?_______________________________ HAVE YOU TRIED CONTACTS BEFORE? YES NO NO NO NO GENERAL EYE QUESTIONS HAVE ANY FAMILY MEMBERS EVER HAD CATARACTS RETINAL DISORDERS LAZY EYE YES YES YES NO NO NO BLINDNESS GLAUCOMA STRABISMUS YES YES YES NO NO NO DO YOU NOW OR HAVE YOU EVER USED ALCOHOL TOBACCO DRUGS YES YES YES NO NO NO FREQUENCY_______________________________________ FREQUENCY_______________________________________ FREQUENCY_______________________________________ LIVING SITUATION DO YOU RESIDE IN: HOME CURRENT MEDICATIONS _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ APARTMENT WITH FAMILY DOSAGE __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ _________________________________________ PATIENT SIGNATURE FRIENDS ALONE EVER HAD ALLERGIC REACTION TO ANY MEDICINE(S)? If So, List _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _____________________ DATE REV. 08/16/04 Last printed 5/19/2005 3:16:00 PM
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