Office Forms for Patients:
1) Preoperative (Before Eye Surgery) History and Physical Examination Form for Patient's Primary Doctor:
PREPROCEDURE HISTORY & PHYSICAL
DATE: __________ TIME: _________ REFERRING
PHYSICIAN: _______________________________________________
CHIEF COMPLAINT:
___________________________________________________________________________________________________
HPI:
___________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PAST MEDICAL HISTORY
Surgery/Anesthesia:
______________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Medical Illnesses:
_______________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MEDICATIONS: ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
ALLERGIES:
___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
FAMILY HISTORY/SOCIAL HISTORY:
___________________________________________________________________________________
________________________________________________________________________________________________________________________
MANDATORY PREOPERATIVE
REVIEW OF SYSTEM-REQUIRED OF ALL PATIENTS UNDERGOING SURGERY
Respiratory ___________________________________________
Hematologic __________________________________________________
Cardiovascular
________________________________________ Gastrointestinal
_______________________________________________
Neurologic
____________________________________________ Endocrine
____________________________________________________
ADDITIONAL
SYSTEMS REVIEW AS CLINICALLY INDICATED – (If reviewed, indicate with a check
and record abnormal results)
_____Constitutional
____________________________________
____Musculoskeletal____________________________________________
_____Eyes_____________________________________________
____Skin/Breast_______________________________________________
_____Ears, Nose,
Throat, Mouth__________________________
____Psychiatric________________________________________________
_____Genitourinary____________________________________
____Allergic/Immunologic______________________________________
PHYSICAL EXAMINATION
– REQUIRED OF ALL PATIENTS UNDERGOING SURGERY
General Appearance:
____________________________________________________________________________________________________
Vital Signs:
BP________ Pulse________ Weight________ Height_________
HEENT: □ Normal □ Other____________________________________________________________________________
Respiratory/Lungs:
Respiratory Effort: □ Nonlabored □
Other_______________ Auscultation: □ Clear______ □ Other________
Cardiovascular:
Heart Auscultation: Rhythm_______
Murmurs_______ Carotid Arteries: Bruits____________
Gastrointestinal: □ Normal
Abdomen: Masses:_______ Tenderness_______
Liver/Spleen: □ Not Palpable__________ □ Other___________
Neurologic: □ Normal
□ Note any gross deficits:____________________________________________________
Signature:_________________________________
Date:____________________ Print Name:__________________
2) New Patient Medical History Forms (Please print forms, fill them out completely & bring to your eye exam):
MEDICAL HISTORY QUESTIONNAIRE
Name:
______________________________________________
Date: __________________________
Date of Birth: _____________________ Date of last eye exam:
__________________________
List all medications you currently take
(prescription and over-the-counter)
________________________
____________________________________________________________________________________
Do you have any allergies to
medications? Yes ____
No ____
If yes, list the medications: _____________________________________________________________
List all major illnesses (glaucoma, diabetes,
high blood pressure, heart attack, etc.) and injuries (concussion, broken bones
etc.) ___________________________________________________________
List any surgeries you have had
(cataract, appendectomy):
_____________________________________
Do you currently have
any problems in the following areas? If YES,
please provide additional info.
Yes
No Details
Eyes (poor vision, eye pain, tearing, redness, etc.)
General Constitution (fever, heat stroke, weight
loss, weight gain, unusually tired)
Ears,
Nose, Throat
(hard of hearing, stuffy nose,
Ear aches, cough, dry mouth)
Cardiovascular (high BP, racing pulse, etc.)
Respiratory (congestion, wheezing,
shortness
of breath, etc.)
Gastrointestinal (stomach upset, diarrhea,
constipation,
hernia, ulcers, etc.)
Genital, Kidney, Bladder (painful urination,
frequent urination, impotence, yellow jaundice, etc
Female, are you pregnant or nursing?
Muscles,
Bones, Joints
(joint pain, stiffness,
swelling, cramps, arthritis, etc.)
Skin (pimples, warts, growths,
rashes, etc.
Neurological (numbness, headaches,
seizures, paralysis, etc.)
Psychiatric (anxiety, depression, insomnia)
Endocrine (diabetes, hypothyroid, etc.)
Blood/Lymph (bleeding, anemia, problems related
to blood transfusion, etc.
Allergic/Immunologic (sneezing, swelling,
redness,
itching, hives, lupus, etc.)
FAMILY HISTORY – (Please circle all that
apply) Mother, Father, Grandparent, Siblings
Has any member of your family had any of the
following diseases? Yes ____ No ____
Unknown ____
Blindness, Cataract, Glaucoma, Diabetes,
Hypertension, Heart Disease, Stroke, Cancer, Thyroid Disease, Arthritis or
other inheritable diseases?:
SOCIAL HISTORY: Smoking:
____packs/day ____cigs/day x ___years,
Alcohol ____glass/day ___yrs
Blood Transfusions? Yes/No ____year,
Intravenous Drug Abuse at any time in past? Yes/No ____years, Married___Divorced___
Separated___ Children/ages ______boys, _____girls, Retired ___Yes ___No
Occupation: ___________ Vision limit any daily activities (driving, reading,
sports, work)? __Yes __ No
Patient’s
Signature
___________________________________________________
Physician
Signature ___________________________________________________
Name: ________________________________________ Age: ____
Birth Date: ___________
Today’s Date: ________________________________
MEDICAL HISTORY
- circle
appropriate answer & EXPLAIN PROBLEM
(e.g., age problem diagnosed, complications, what doctor is
treating this condition?)
Respiratory (emphysema/Bronchitis) Yes No ____________________________________
Cardiovascular (Heart) Yes No ____________________________________
Stomach/Intestines Yes No ____________________________________
Kidney/Bladder/Genitals Yes No ____________________________________
Muscle/Joint Aches & Pains Yes No ____________________________________
Neurological (MS, Seizure disorder) Yes No ____________________________________
Psychiatric Yes No ____________________________________
Endocrine (Diabetes/Thyroid) Yes No ____________________________________
Blood/Lymph Nodes/Swelling Yes No ____________________________________
Allergies (seasonal hay fever, sinus, chronic cough, runny
nose) Yes No
_________________
OCULAR HISTORY- Please
circle the appropriate answer
Recent fever Yes No ____________________________________
Recent unexplained weight loss Yes No ____________________________________
___ Vision Loss? __ Double vision? Yes No Onset_____Duration_____Which Eye?____
Blurred Vision Yes No ____________________________________
Distorted Vision (halos) Yes No ____________________________________
Loss of side vision Yes No ____________________________________
Dryness in eyes Yes No ____________________________________
Mucous discharge Yes No ____________________________________
Redness in __one or __both eyes Yes No ____________________________________
Sandy/Gritty/foreign body sensation Yes No ____________________________________
Itching or burning Yes No ____________________________________
Tearing/Watering Yes No ____________________________________
Glare/Light sensitivity Yes No ____________________________________
Eye Pain or soreness Yes No ____________________________________
Chronic infection of eye/lid,
stye or chalazion Yes No ____________________________________
Fluctuating visual acuity Yes No ____________________________________
Tired Eyes Yes No ____________________________________
Name:
_________________________________________Age: _____ Birth Date: ___________
Today’s Date:
______________________________
FAMILY HISTORY-
Please circle the appropriate answer and list relationship, Mother, Father,
Brother, Sister, Aunt, Uncle, Grandparent
DISEASE RELATIONSHIP
TO PATIENT
Blindness Yes No ____________________________________
Cataract Yes No ____________________________________
Glaucoma Yes No ____________________________________
Macular Degeneration Yes No ____________________________________
Retinal detachment Yes No ____________________________________
Arthritis Yes No ____________________________________
Cancer (what kind) Yes No ____________________________________
Diabetes Yes No ____________________________________
Heart Attack Yes No ____________________________________
High Blood Pressure Yes No ____________________________________
Kidney Disease Yes No ____________________________________
Lupus Yes No ____________________________________
Sjogrens Syndrome Yes No ____________________________________
Stroke Yes No ____________________________________
Thyroid Disease (Hypo or Hyper) Yes No ____________________________________
Tuberculosis Yes No ____________________________________
Other Yes No ____________________________________
SOCIAL HISTORY – Current Occupation:
_________________________________________
Do you drive? Yes
No
Do you have visual difficulty when
driving? Yes No
Do you have problems with night
vision? Yes No
Have you ever tried to wear contact
lenses? Yes No
How long since your last complete
eye exam? Mo__Year___Eye Doctor___________
Do you drink alcohol? Yes No How
many ounces a day? ________
Do you smoke? Yes No Packs
per day? ___ x ___ years
Have you ever had a blood
transfusion? Yes &n
