Patient History Form Step 1 of 3 33% Patient History FormPlease complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Please help us take better care of your overall health by completing the following formName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Number*Please provide a telephone number, with area code, so we can contact you.Cell PhoneWork PhoneEmail AddressPlease provide your email address.EmployerOccupationDate of Birth* Date Format: MM slash DD slash YYYY Social Security Number (last 4 digits only!)Please enter a number from 0000 to 9999.Race/EthnicityPreferred LanguageGenderFemaleMaleWho may we thank for referring you to our office?Date of Last Medical ExamName of Medical DoctorDoctor's Phone NumberDate of Last Eye ExamCurrent HeightCurrent WeightSpouse or Guardian (If Applicable)PLEASE CHECK ALL THAT APPLYOCULAR HISTORY Cataract Glaucoma Retinal Detachment Macular degeneration OCULAR SURGERY Cataract Glaucoma Retinal Laser MEDICAL HISTORYMedicationsAllergy MedsAllergy OtherREVIEW OF SYSTEMSCARDIOVASCULAR Elevated Cholesterol Heart Disease Hypertension ENDOCRINE Crohn’s Disease Diabetes Mellitus Pituitary Disorder Renal (kidney) Disorder Thyroid Disorder GASTROINTESTINAL Acid Reflux Cancer, Colon, Liver, Lung Gall Bladder Hepatitis Gastritis Pancreatitis GENITOURINARY Ovarian Disorder Prostate Disorder EAR, NOSE, MOUTH, THROAT Dry Mouth Ear Infection Headaches Migraine Headaches Sinusitis IMMUNOLOGIC Acquired Immune Deficiency Herpes Simplex Herpes Zoster HIV Positive Lyme Disease Measles Mumps Rubella Sarcoid Sjogren’s Syndrome Tuberculosis NEUROLOGICAL Bell’s Palsy Headache Headache Migraine Nystagmus Parkinson’s Disease Seizure Disorder RESPIRATORY Asthma Bronchitis Lung Disease Smoker Tuberculosis HEMATOLOGIC/LYMPHATIC Anemia Blood Coagulation Disorder Blood Disorder Sickle Cell Disease INTEGUMENTARY (SKIN) Acne Acne Rosacea Dermatitis Lupus MUSCULOSKELETAL Arthritis Muscular Dystrophy Myasthenia Gravis Skeletal Disorder PSYCHIATRIC Anxiety Disorder Dementia Depression Mood Disorder PRIMARY CARE PHYSICIANPHONEFAX Medical HistoryDo you have any allergies to medications?NoYesIf Yes, list medication(s) and reaction below:List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:Include Name of Medication, Dosage, Frequency TakenList all major injuries, surgeries and/or hospitalizations you have had:Check any of the following that you have had: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Cataracts Glaucoma Iritis/Uveitis Macular Degeneration Retinal Disease of Detachment Eye Infections Eye Injury Corneal Problems Other Eye Disorders If Other Eye Disorders, please explain:Are you pregnant or nursing?NoYesDo you wear glasses?NoYesIf Yes, how old is your present pair of lenses?Do you wear contact lenses?NoYesIf Yes, how old is your present pair of lenses?Type of Contact Lenses: Rigid Soft Extended Wear Other Are they comfortable?NoYesFamily HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.Disease/Condition Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment or Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Thyroid Disease Other If Other, please explain:If Yes to any of the above, please explain:Social HistoryThis information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.I prefer to discuss my Social History information directly with my doctor. Yes Do you drive?NoYesIf Yes, do you have visual difficulty when driving?NoYesIf Yes, please describe:Do you use tobacco products?NoYesIf Yes, list type/amount/how long:Do you drink alcohol?NoYesIf Yes, list type/amount/how long:Do you use illegal drugs?NoYesIf Yes, list type/amount/how long:Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphillis Eye Care LifestyleIs UV protection important to you?YesNoAre your eyes sensitive to bright light?YesNoOn average, how much time per day do you spend outside in direct sunlight?None30 minutes to 1 hour2 to 4 hoursMore than 4 hoursWhat type(s) of activities do you engage in outdoors? Check all that apply. Driving Running Tennis Walking Hiking Biking Golfing Gardening Other If you chose Other, please specify.Do you currently own sunglasses?YesNoIf yes, what brand?How do you currently protect your eyes from harmful UV rays?REVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?ConstitutionalFever, Weight Loss/GainNoYesIntegumentary (Skin)NoYesNeurologicalHeadachesNoYesMigrainesNoYesSeizuresNoYesEyesLoss of VisionNoYesBlurred VisionNoYesDistorted Vision/HalosNoYesLoss of Side VisionNoYesDouble VisionNoYesDrynessNoYesMucous DischargeNoYesRednessNoYesSandy or Gritty FeelingNoYesItchingNoYesBurningNoYesForeign Body SensationNoYesExcess Tearing/WateringNoYesGlare/Light SensitivityNoYesEye Pain or SorenessNoYesChronic Infection, Eye or LidNoYesSties or ChalazionNoYesFlashes/Floaters in VisionNoYesTired EyesNoYesEndocrineThyroid/Other GlandsNoYesElevated CholesterolNoYesCancerNoYesEars, Nose, Mouth, ThroatSinus CongestionNoYesRunny NoseNoYesPost-Nasal DripNoYesChronic CoughNoYesDry Thoat/MouthNoYesAllergies/Hay FeverNoYesRespiratoryAsthmaNoYesChronic BronchitisNoYesEmphysemaNoYesVascular/CardiovascularDiabetesNoYesHeart PainNoYesHigh Blood PressureNoYesVascular DiseaseNoYesGastrointestinalDiarrheaNoYesConstipationNoYesGenitourinaryGenitals/Kidney/BladderNoYesBones/Joints/MusclesRheumatoid ArthritisNoYesMuscle PainNoYesJoint PainNoYesLymphatic/HematologicAnemiaNoYesBleeding ProblemsNoYesAllergic/ImmunologicAllergic/ImmunologicNoYesPsychiatricPsychiatricNoYesIf you answered Yes to any of the above or have a condition not listed, please explain and list medications:Patient SignatureDate Date Format: MM slash DD slash YYYY We at Broward Eyecare are pleased to provide our patients the most advanced digital retinal diagnostic technology currently available called Eye Wellness. Eye Wellness allows a much higher resolution view of all the internal eye structures that is possible with conventional instruments. WHAT CONDITIONS DOES EYE WELLNESS HELP IDENTIFY: Macular degeneration Retinal holes Retinal detachment Diabetes retinal damage ( the leading cause of blindness worldwide) Glaucoma WHAT ARE YOUR BENEFITS FROM THE EYE WELLNESS EXAM? An annual photographic record of the retinal surface where eye disease first appear. A CT scan below the surface integrity of all retinal layers not visible with conventional instruments. Permanent record of your medical file to allow monitoring, comparison, and sharing with your primary physician any change that will permit early diagnosis and treatment. In most cases no dilating drops are necessary. Eye Wellness testing is fast, easy and comfortable. Eye Wellness includes medical diagnostic procedure normally covered (minus in-force deductibles and co pays) by medical insurance when a disease is discovered. The eye doctors at Broward Eyecare recommend the Eye Wellness testing for patients on a regular basis. For patients having no medical insurance to cover the procedure Eye Wellness is an out of pocket expense of $43.00 in addition to the comprehensive eye examination charges you are receiving today. I agree to have my retinal health evaluated with Eye Wellness today. I do not wish to have my retinal health evaluated with eyewellness. I understand that I will still have a through and comprehensive eye exam with standard technology. Print Patient Name First Last Date Date Format: MM slash DD slash YYYY Patient SignatureCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
