Patient Health History Update

    Please answer all the questions below.


    Cataracts:

    YesNo

    Glaucoma:

    YesNo

    Macular degeneration:

    YesNo

    Corneal disease:

    YesNo

    Lazy Eye:

    YesNo

    Retinal problems:

    YesNo

    Diabetes:

    YesNo

    Do you take Insulin?:

    YesNo

    High blood pressure:

    YesNo

    Heart disease:

    YesNo

    Asthma:

    YesNo

    Arthritis:

    YesNo

    Thyroid disease:

    YesNo

    Stroke:

    YesNo

    Cancer:

    YesNo

    Migraine headaches:

    YesNo

    Seasonal allergies:

    YesNo

    Wear contact lenses:

    YesNo

    Family history of diabetes:

    YesNo

    Family history of glaucoma:

    YesNo

    Family history of heart disease:

    YesNo

    Family history of cancer:

    YesNo

    2. Have you ever had an injury to your eye(s)

    YesNo


    3. Have you ever had any surgery on your eye(s)

    YesNo



    7. Are you in good health now?

    YesNo

    8. Are you now under the care of a physician?

    YesNo


    9. Have you ever been hospitalized or had a serious illness?

    YesNo


    10. (Women) Are you pregnant?

    YesNo


    11. Do you use tobacco in any form?

    YesNo


    12. Do you use alcoholic beverages (more than 2 drinks per day)?

    YesNo

    13. Do you drive

    YesNo

    GENERAL

    Tire easily, weakness:

    YesNo

    Marked weight change:

    YesNo

    Night sweats:

    YesNo

    Persistent fever:

    YesNo

    SKIN

    Eruptions (rash) hives:

    YesNo

    Change in skin color:

    YesNo

    EARS

    Loss of hearing:

    YesNo

    Ringing in ears:

    YesNo

    NOSE

    Frequent nosebleeds:

    YesNo

    Sinus problems:

    YesNo

    THROAT

    Soreness/horseness:

    YesNo

    NERVOUS SYSTEM

    Stroke:

    YesNo

    Headaches:

    YesNo

    Convulsions/epilepsy:

    YesNo

    Numbness/tingling:

    YesNo

    Dizziness/fainting:

    YesNo

    Psychiatric treatment:

    YesNo

    RESPIRATORY

    Tuberculosis:

    YesNo

    Emphysema:

    YesNo

    Hay fever:

    YesNo

    Persistent cough:

    YesNo

    Sputum production (phlegm):

    YesNo

    Cough up bloody sputum:

    YesNo

    Difficulty breathing while lying down:

    YesNo

    Asthma:

    YesNo

    BARRIERS TO TREATMENT

    Visual Impairment:

    YesNo

    Difficulty Hearing:

    YesNo

    Any language barrier:

    YesNo

    Any cultural barriers to receiving treatment :

    YesNo

    Any religious barriers to receiving treatment :

    YesNo

    HEART/BLOOD VESSELS

    Rheumatic fever:

    YesNo

    Heart murmur:

    YesNo

    Chest pain/discomfort

    YesNo

    Heart attack

    YesNo

    Shortness of breath

    YesNo

    Swelling of ankles

    YesNo

    Heart Surgery

    YesNo

    BONE/MUSCLES

    Rheumatism:

    YesNo

    Artificial joints/limbs:

    YesNo

    DIGESTIVE SYSTEM

    Hepatitis:

    YesNo

    Jaundice:

    YesNo

    Ulcers:

    YesNo

    Change in appetite:

    YesNo

    Black, bloody or pale stools:

    YesNo

    URINARY

    Kidney disease:

    YesNo

    Increase in frequency of urination (night):

    YesNo

    Burning on urination:

    YesNo

    Urethral discharge:

    YesNo

    Bloody urine:

    YesNo

    BLOOD

    Bruise easily:

    YesNo

    Anemia:

    YesNo

    Blood transfusion:

    YesNo

    OTHER

    Radiation therapy:

    YesNo

    Chemotherapy:

    YesNo

    Tumors of growths:

    YesNo

    HIV+:

    YesNo

    AIDS:

    YesNo

    Do you have an Advance Directive or Living Will?:

    YesNo