Download Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire

The Zanvyl Krieger Children’s Eye Center at the Wilmer Institute
Pediatric Ophthalmology and Adult Strabismus
Tel: 410 955-8314
Fax: 410 955-0809
www.wilmer.jhu.edu
at The Johns Hopkins Hospital: Wilmer 233, The Johns Hopkins Hospital, Baltimore, MD 21287-9028
at Green Spring Station: 10755 Falls Road, Suite 110, Lutherville, MD 21093
at Columbia: 5900 Cedar Lane, Columbia, MD 21044
Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire
Page 1: Background Information
As medical doctors as well as eye surgeons, we need to know about more than just the eyes. Please
answer all questions to the best of your ability. Note: Some areas apply only to pediatric patients.
PLEASE BE SURE TO GIVE A COMPLETE REFERRING PHYSICIAN ADDRESS!
Date of first appointment with us:
Family Physician (or Pediatrician):
Patient's Name:
Mailing Address:
(Important! We must have an accurate address):
Street:
City:
State:
Zip:
Home Phone:
Home Fax:
Phone:
Email:
Fax:
Other Physician(s) not listed above who should receive a report (please give name, specialty, address, and phone):
Were you referred to us by your family physician (or pediatrician)? q Yes q No
If "no," who referred you, or how did you hear of us?
Please indicate above if you prefer that we not send a report to any of the above physicians.
This Section For Pediatric Patients:
Parents are qMarried qSeparated qDivorced
q Living with parent(s)
qLiving with relative, guardian, or foster parent
Full Name of Father (or Guardian):
Full Name of Mother (or Other Guardian) :
Family Status - Patient is:
Occupation:
Occupation:
Daytime Phone:
Daytime Phone:
Other Phone:
Email:
Fax:
Other Phone:
Fax:
Email:
Rev 5/99 dgh
Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire
Page 2: Occupation and Ocular History
Occupation (or school grade if student):
If retired, occupation before retiring:
If college or graduate student, area of study:
Name of employer (or name of school if student):
Pediatric patients: List names and ages of brothers and sisters:
History of Eye Problems:
Yes No Glasses/Contact lenses/Prisms
q
q
q Glasses
q Contact lenses
q
Hard, Gas permeable, or Soft?
q Prisms
Yes No Other eye symptoms
How old is current pair?
How old is current pair?
Contact lens cleaning solutions:
How long?
Age or How Long?
q q
q q
q q
q q
q q
q q
Diagnosed eye diseases not mentioned above:
Eye exam by specialist
Patching
Eye exercises
Eye muscle surgery
Other eye surgery
Yes No Other eye symptoms
q
q
q
q
q
q
q
q
q
q
q
q
Eye injury
Stye
Recurring “pink eye”
Cataract
Glaucoma
Diabetic eye disease
Recent Eye Symptoms:
Yes No
How long?
q q Crossed or wandering eye
q q Excessive squinting
q q Double vision
q q Excessive eye rubbing
q q Frequent tearing or discharge
q q Blurred vision
q q Light sensitivity
Other eye symptoms not mentioned above:
Yes No
q
q
q
q
q
q
q
q
q
q
q
q
q
q
How long?
Drooping eye lid
Tired eyes when reading
Dry or gritty sensation
Itching eyes
Red eyes
Flashing lights or floaters
Poor peripheral vision
Age or How Long?
Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire
Page 3: Recent Symptoms and Family History
Other Recent Symptoms:
Yes No Symptom
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
How long?
Weight loss
Excessive fatigue
Fever
Earaches
Sore throat
Dry mouth
Chest pain
Rapid heart rate
Shortness of breath
Swelling of hands/feet
Loss of appetite
Vomiting
Yes No Symptom
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Diarrhea/constipation
Frequent/painful urination
Blood in urine
Muscle weakness
Rash
Headaches
Dizziness
Numbness
Paralysis
Memory loss
Change in school performance
Clumsiness
Family History: Which of the patient's relatives have had any of the following?
Yes No Eye Conditions in other family members:
Which relative? (Circle or fill in.)
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Father Mother Sister Brother Other:
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Glasses before age 6
Amblyopia (“lazy eye”)
Patching treatment
Strabismus (“crossed” or “wandering” eye)
Eye muscle surgery
Cataracts in childhood
Cataracts
Glaucoma in childhood
Glaucoma
Blindness in childhood
Blindness (why?)
Eye injury
Eye disease caused by diabetes
Macular degeneration
Retinal detachment
Other serious eye disease in childhood
Other serious eye disease (describe):
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Yes No Medical conditions in other family members:
Which relative (circle or fill in)?
q
q
q
q
q
q
q
q
Father Mother Sister Brother Other:
q
q
q
q
q
q
q
q
Complications from anesthesia
Genetic disease (runs in family)
Heart disease
Diabetes
High blood pressure
Stroke
Cancer
Other serious illnesses in family members:
Are both parents alive and in good health?
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
Father Mother Sister Brother Other:
How long?
Adult Strabismus and Pediatric Ophthalmology - New Patient Questionnaire
Page 4: Medical History
Medical History
Yes No Condition
Yes No Condition
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Frequent ear infections
Sinus disease
Heart disease
High blood pressure
Asthma
Other lung disease
Arthritis
Thyroid problem
q
q
q
q
q
q
q
q
Diabetes
Anemia
Kidney disease
Neurologic disease
Seizures or stroke
Depression
Cancer
Missing immunizations
Major illnesses not mentioned above (other than eye problems):
Previous surgery or other hospitalizations:
Medications
List any eye drops the patient is taking: q NONE
Eye drop and frequency
Why is this medication being used?
List any medications the patient is taking: q NONE
Medication and dosage (if known)
Why is this medication being used?
List any known allergies to medications: q NONE
Medication
Reaction
Birth history (Pediatric patients only): Birth weight: ____ lb, ____ oz
Yes No Condition
Please provide details
q
q
q
q
q
q
q
Describe:
Describe:
q
q
q
q
q
q
q
Problems during pregnancy
Problems during delivery
Forceps delivery
Cesarean section
Delivered early or late
Baby kept in hospital due to illness
Delayed development
How many weeks?
Why and how long?
Describe:
Reviewed by: Dr. ________________