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Theeyeinstitute.com

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

Source: http://www.theeyeinstitute.com/wp-content/uploads/2013/03/Patient-History-Form-EIU_NEW-MASTER.pdf

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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

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