Patient Past/present Eye History Form

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Review of Systems Form
Patient name Label
Date:
Your Past /Present Eye History
Review of Systems
Do you have or have you had any of the
Do you have or have you had any of the
following: Please check appropriate response
following: Please check yes or no to each.
in every box.
Yes
No
Diabetic Eye Disease
Glaucoma
Ears, Nose, Mouth, Throat
Yes
No
Macular Degeneration
Hard of Hearing
Cataracts
Sinus Headaches, Hay Fever
Cataract Surgery
Other Ear Nose or Throat Problems
Breathing Respiratory Health
Laser Surgery RK, LASIK, Other:
Eye Injury
Breathing Problems, Emphysema or Asthma
Crossed or lazy eye
TB (Tuberculosis)
Heart/Vessels - Cardiovascular
Retinal Detachment
Other:
High Blood Pressure
Your Social History
Stroke
Do you use any of the following?
Heart Problems: ________________________
Drink Alcohol?
General
Use Medical Marijuana?
Drink Caffinated Beverages?
Recent, unexplained weight loss/gain
Smoke?
Tumor or Cancer - Type: _________________
If quit smoking, at what age?______
Hepatitis B C
Past Surgeries List each: _________________
Family Medical History
Have your parents, brothers, sisters and/or
grandparents ever been affected by any of the
following: Please check yes or no to each.
Diabetes
Stomach/Bowel - Gastrointestinal
Macular Degeneration
Stomach or intestinal problems
Glaucoma
Jaundice or Liver Disease
Retinal Detachment
Genitals/Urinary - Genitourinary
Blindness
Genital/Urinary problems
Bleeding or Blood Clotting issues
Kidney Problems
Tumors of the eye
On Medication for urine flow
Bone/Muscle - Musculoskeletal
Other:
Arthritis/Bone or Joint Problems
Skin/Tissue - Integumentary
Medications
Dermatology Problems
Skin Cancer
List all medications, herbs, supplements you are currently taking
Med:
Strength
Times per Day
Nerve - Neurological
Seizures
Head Injury
Multiple Sclerosis
Endocrine
Thyroid Disease
Diabetes Do you use insulin? Y
N
Blood/Bleeding - Hematologic/Lymph
Bleeding or blood clotting disorder/Anemia
High cholesterol
Psychiatric
Rvd by:
Date
Rvd by:
Date
Depression/Anxiety/Insomnia/Mental Illness
Rvd by:
Date
Rvd by:
Date
Allergic/Immunologic
Rvd by:
Date
Rvd by:
Date
HIV/AIDS
Rvd by:
Date
Rvd by:
Date
Lupus/Sjogrens
Allergies to Medications: _________________

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