oday’s Date: ________________ Account # ________________ A
Today’s Date: ________________ PATIENT HISTORY FORM Patient Name: Date of Birth: _____________ Primary Care Physician: Optometrist: __________________________________ Cardiologist: _________________________________________ Endocrinologist: __________________________________ Pharmacy: _________________________________ Pharmacy Phone # ( )___________________________________ History of Latex Allergy?
NO Have you or any family members had an anesthesia reaction? Medication Allergies & Reactions: ___________________________________________Occupation:_____________________ Medical History Do you now, or have you ever had: Current Treatment/ Previous Surgery Diabetes (Type) Heart Disease Pacemaker / Defibrillator High Blood Pressure High Cholesterol Kidney Disease ( Dialysis Liver Disease Asthma or Lung Disease Thyroid Disease: Overactive Underactive Cancer or Tumor (Type) Arthritis (Type) Other Medical Problems or Surgeries: FAMILY HISTORY: Relationship SOCIAL HISTORY:
No Retinal disease ______________ Caffeine:
No Other eye/medical problems_________________________
Please list Prescribed and Over-The-Counter Medications, including vitamins and supplements, you are currently taking: Name of Medication Reason for taking Name of Medication Reason for taking Have you ever taken any of the following medications? If Yes, please check box Finasteride Uroxatral
Patient Name: _______________________________ Acct#: _________________
Ocular History Do you currently have, or Current Treatment/ Diagnosis have you ever had: Previous Surgery Eye disease Eye Injury Eye Surgery REVIEW OF SYSTEMS - Do you currently have any problems in the following areas? Constitutional: Fever Neurological: Dizziness Cardiovascular: Chest Pressure or Discomfort Musculoskeletal: Muscle Weakness Metabolic/ Intolerant to: Endocrine: Excessive Thirst (polydipsia) Respiratory: Difficulty Breathing (dyspnea)
Urinating more than usual (polyuria) Integumentary/Skin: Genitourinary: Painful Urination (dysuria) Psychiatric: Depressed Mood Hematologic/Lymphatic: ENT: Hearing Loss
Swollen Lymph Nodes (lymphadenopathy) Allergic/Immunologic: Gastrointestinal: Abdominal pain FEMALES: Are you Pregnant or Nursing? VISUAL FUNCTION QUESTIONS
Please check Yes or No if you are having any difficulty with the following while wearing your glasses or contacts (if applicable)
Comments
Taking part in sports (i.e. golf, tennis)
Are you satisfied with your current vision?
Please list all individuals you authorize to receive information about your care: Individual Relationship
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Social media in health – what are the safety concerns for health consumers? Annie Y.S. Lau, Elia Gabarron, Luis Fernandez-Luque and Manuel Armayones Abstract Recent literature has discussed the unintended consequences of clinical information technologies (IT) on patient safety, yet there has been little discussion about the safety concerns in the area of consumer health IT . This
oday’s Date: ________________ Account # ________________ A
Today’s Date: ________________