Arizona Glaucoma Specialists (www.azglaucomaspecialists.com) Tucson (520) 544-4393 Fax (520) 544-0098 Phoenix (480) 538-7075 Fax (480) 538-7952
Name:____________________________________ Date:___/___/____ Age/DOB:___________________________
Referred by:________________________________ Primary Care Physician:________________________________
Please fill out FRONT AND BACK of this page by checking or circling all that apply. Is there a family history of Glaucoma? Glaucoma Suspect? Y N (Mother, Father, Brother, Sister, Other________) EYE HEALTH QUESTIONS Details (Dates, Doctors, etc.) Decreased vision
Sharp – Dull – Constant – Intermittent – Upon awakening(morning) – Evening/Night
Constant – Intermittent – Upon awakening(morning) – Day - Night
Haloes around lights Floaters Flashes of light Fluctuating/Distorted vision Double vision Dryness/ Sandy feeling Itching/Burning Glare/Light Sensitivity Discharge/Infection Drooping eyelid Crossed eye/ Lazy eye Excess tearing/ watering Glaucoma
Suspect - Open Angle - Closed Angle – Steroid Related – Childhood – Injury Related – Pigmentary - Other
Glaucoma Surgery
Trabeculectomy w/ (Mitomycin, 5 FU) – Shunt – Other
Glaucoma Laser
Iridotomy – Laser Trabeculoplasty (ALT, SLT)
High eye pressure Cataract Cataract Surgery/YAG Laser Retinal detachment
Buckle – Laser Treatment – Cryo - Vitrectomy
Macular degeneration/ hole Diabetic eye disease Retinal Vein/Artery Occlusion Eye injury Corneal Transplant Glasses/Contact Lenses
Reading – Distance – Soft Lenses - RGP
CURRENT EYE MEDICINES # DROPS PER DAY Xalatan – Lumigan - Travatan(Z) Alphagan P (brimonidine) 0.1% 0.15% 0.2% Timoptic(XE) -Timolol(GFS) - Betimol - Optipranolol 0.25% 0.5% Betagan(levobunolol) - Betoptic S - Ocupress 0.25% 0.5 % Cosopt – Azopt - Trusopt Pilocarpine 0.5% 1% 2% 4% (gel) Diamox (Sequel) (acetazolamide) 250mg 500mg Neptazane (methazolamide) 25mg 50mg
Are there any glaucoma medications you have taken previously? Y N _____________________________________ Are there any glaucoma medications you could not tolerate (allergies)? Y N _______________________________ What have your highest eye pressures been? (Pre-Treatment, Post-Treatment) RT___ LT___ Date ________Unknown Please list all other medications you currently are using (prescription, over-the-counter, herbs, vitamins, supplements): 1_______________________4______________________7______________________10________________________2_______________________5______________________8______________________11________________________3_______________________6______________________9______________________12________________________ Please list all other past surgeries (from birth to present): 1_______________________4______________________7______________________10________________________2_______________________5______________________8______________________11________________________3_______________________6______________________9______________________12_______________________ List all allergies: __________________________________________________________________________________
MEDICAL HISTORY Diabetes (How many years?) Breathing Problems or Treatments Heart Problems or Treatments
Heart Attack – Arrhythmia – Irregular Heartbeat
Blood Pressure Problems or Treatments Stroke – Seizure, other Neurologic Problems Depression – Psychiatric Problems or Disorders Kidney Stones – other Genital/Urinary Disease Currently Pregnant Arthritis, Lupus, Thyroid, or Raynaud’s Disease Skin Cancer – other Skin Disease Sinus Problems – Ear/Nose/Throat problems Ulcers – other digestive problems Steroid Use
Inhalation – Oral Prednisone – Injection – Cream/Lotion
Blood Loss – Anemia – Blood Transfusion Migraine Social History
Occasional – 1/day – 2-3/day – 4+/day
Do you smoke? Quit? When? _______________
Occasional – 1/2pack/day – 1pack/day – 1+pack/day
The above information is true and correct to the best of my knowledge. Patient Signature: _________________________________________ Date: __________________ History Reviewed No Changes Additions as noted Technician Initials: _______ Doctor’s Signature: __________________________________________ Date: ___________________ TO BE FILLED OUT BY STAFF – Pulse_________ __________
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