Download C:\Users\Jonathan J Carbaugh\AppData\Local\Temp

Barry S. Zelesnick, O.D., F.A.A.O.
Name 0 0
PATIENT HISTORY AND INFORMATION
PRIMARY CARE PHYSICIAN
Primary Care Physician and Clinic Name
Address of Primary Care Physician
City
State Zip
City
State Zip
Phone
REFERRING PHYSICIAN
Referring Physician and Clinic Name
Address of Referring Physician
HEALTH HISTORY
What is the main reason for today's exam ?
Phone
When was your last exam ?
When was your last health exam ?
Past Illnesses or Injuries:
Past Surgeries:
Current Medications:
Current Eye Drops:
Medicines that cause reactions or sensitivities:
Specific Allergies:
Current Eye Symptoms
Glaucoma
Cataract
Macular Degeneration
Retinal Detachment
Color Blindness
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (Lazy Eye)
Burning
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Dryness
Excess Tearing/Watering
Eye Pain or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping Eyelid
Redness
Sandy or Gritty Feeling
GENERAL HEALTH CONDITION
Fever
Respiratory (Asthma)
Yes
No
Weight Loss
Yes
No
Gastrointestinal
Other Symptoms
Yes
No
Kidney
Muscles,Bones,Joints
Yes
No
Ears,Nose,Throat
Skin
Yes
No
Cardiovascular (high
blood pressure etc.)
Neurological (Multiple Sclerosis)
FAMILY HISTORY
Amblyopia (Lazy Eye)
Blindness
Cataract(s)
Color Blindness
Glaucoma
Macular Degeneration
Name 0 0
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Retinal Detachment
Strabismus (Eye Turn)
Arthritis
Cancer
Diabetes
Heart Disease
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Strabismus (Crossed Eyes)
Blurred Vision Distance
No
No
Blurred Vision Near
No
Distorted Vision (halos)
No
Double Vision
No
Floaters or Spots
No
Fluctuating Vision
No
Loss of Vision
No
Loss of Side Vision
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Anxiety or Depression
Endocrine (Thyroid, Diabetes)
Blood/Lymph
Allergic
Are you?
No
No
No
No
No
No
High Blood Pressure
Kidney Disease
Lupus
Barry S. Zelesnick, O.D., F.A.A.O.
Stroke
Thyroid Disease
Others
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Pregnant
Nursing
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
MEDICAL HISTORY QUESTIONAIRE
SOCIAL HISTORY
Current Occupation :
Years
SPECTACLE LENS HISTORY
Do you use a computer?
Do you drive?
Yes
Yes
No How many hours/day?
Distance from Computer?
No Mileage to work each way?
Yes
Do you currently wear glasses ?
FullTime
No
Since
No
PartTime
No
No
Yes
Do you have problems with night vision?
Yes
Do you have glare problems?
Yes
Do you have visual difficulty when driving?
Type of glasses
Employer
Distance
Close
Glasses Owned
SingleVision
Bifocals
Trifocals
Backup
Safety
Yes
Have you had trouble in the past with glasses?
Yes
Do you wear sunglasses?
Sports
No
No
Yes
Are your sun glasses your current prescription ?
SPECIAL EYEWEAR NEEDS
Computer (special prescriptions, special anti-glare tints or coatings)
Occupational (mechanics, plumbers, pilots)
CONTACT LENS HISTORY
Have you ever tried to wear contact lenses?
Yes
Yes
Do you currently wear contact lenses?
Progressive
Safety Glasses (gardening, woodworking, welding)
Sports/Hobbies (racquet sports, motorcycle)
No
No
Reason for stopping?
Since
Yes
If not a contact lens wearer, are you interested in trying contact lenses at this time ?
Type and brand of contact lenses
No
Today's wearing time ?
How many hours/day ?
How many days/week ?
Please rate the following on a scale of 1-10, with 1 being POOR to 10 being EXCELLENT
Right
Left
Right
Right Left
Distance Vision
Near Vision
Lens Comfort
What Solutions do you use?
Cleaner
Disinfectant
Left
Enzyme
SOCIAL HISTORY
Yes
Do you use nutritional supplements (vitamins etc.)?
Do you engage in regular exercise?
Do you drink alcohol ?
Do you smoke ?
Yes
If yes, how much/often :
If yes, how much/often :
No
No
No
No
Occasional
Occasional
Method of Tobacco Intake :
Smoking
Do you use Illegal Drugs :
Yes
Hobbies/ Interests :
Last Health Exam
No
No
Chewing
1 per day
1/2 pack/day
2-3/day
1 pack/day
4+/day
1+ pack