Medical History Questionnaire

Merrimack Eye Clinic – John Capino, MD Page 1 of 2 MEDICAL HISTORY AND REVIEW OF SYSTEMS

Name ______Date ______Date of birth ______Primary Care (Regular) Doctor: ______Last eye exam (Date/Physician) ______List all medications you currently take (prescription and over-the-counter): ______List all medications you have allergies, if any? ______List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) and injuries (concussion, etc.):______List all eye injuries you have had: ______List any surgeries you have had (eye surgery/laser, cataract, tonsillectomy, heart, appendectomy, etc.): ______Have you ever tried to wear contact lenses?  YES  NO Do you currently wear contact lenses?  YES  NO If YES, how long have you worn contact lenses? ______Do you currently wear glasses?  YES  NO If YES, how long have you had the current prescription? ______Do you currently have any problems in the following areas? EYES YES NO Explanation of Problem Cataract Glaucoma Blurry vision (on fine print? Distance?) Near  Distance  Both Loss of side vision Tired eyes - Eye Strain Seeing Flashes - Fluctuating vision Distorted vision - Seeing halos Seeing Floaters? Spots? Glare - light sensitivity Dry eyes Discharge from eyes Redness or red eyes Sandy or gritty feeling Itching eyes Burning eyes Foreign body sensation Excess tearing? Eyes watering? Double vision Eye pain or soreness Infection of eye or lid (blepharitis, stye) Loss of vision Crossed eyes - lazy eye Drooping eyelid Other eye problems? DO YOU HAVE NOW OR HAVE YOU EVER HAD: GENERAL/CONSTITUTIONAL YES NO Dates/Explain Unexplained fever, chills, night sweats, unexplained fatigue? Gained or lost more than 10 pounds in the last year? EARS, NOSE, THROAT Loss of hearing/smell, Sinus, ear infection, chronic cough, dry mouth, bleeding? CARDIOVASCULAR Heart or circulation problems? Heart YES NO attack? Shortness of breath? Pacemaker? High blood pressure? Merrimack Eye Clinic – John Capino, MD Page 2 of 2 RESPIRATORY Asthma? Emphysema? Chronic cough? Bronchitis? Tuberculosis? GASTROINTESTINAL Stomach ulcers? Intestinal disease? Hepatitis? Colitis? Liver disease? Hepatitis (type____)? GENITOURINARY, KIDNEY, BLADDER, PROSTATE PROBLEMS? Stones? Infection? Frequency, VD? MUSCLES, BONES, JOINTS Arthritis? Joint swelling, low back pain, rheumatoid? Gout? SKIN Acne, warts, skin cancer, eczema, resaca, infection? NEUROLOGICAL –Tremor, seizures, hallucinations, disorientation, Multiple sclerosis, memory loss, etc.? PSYCHIATRIC Anxiety, depression, insomnia? ENDOCRINE - Diabetes, thyroid problems? Grave’s dis? BLOOD/LYMPH anemia, easy bruising, swollen glands etc? ALLERGIC/IMMUNOLOGIC seasonal allergies? Recurrent infections? Chronic runny nose & watery eyes? Lupus? CANCER or TUMOR: Type, location, date, treatment Other medical problems: FAMILY HISTORY: Among your blood relatives, is there a history of the following: DISEASE YES NO RELATIONSHIP TO PATIENT Night Blindness Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Color Blindness Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Cataracts Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Glaucoma Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Macular degeneration Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Amblyopic, or “lazy eye” Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Retinal detachment or retinal problems? Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Crossed Eyes Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Diabetes Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Cancer/tumor Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Heart disease or high blood pressure Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Kidney disease Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Lupus Mother ( ) father ( ) brother/sister ( ) grandparent ( ) Others? Mother ( ) father ( ) brother/sister ( ) grandparent ( ) SOCIAL HISTORY: Current occupation______Living arrangements: home: _____apartment _____nursing home:______others (shelter?/?):______Do you live alone?  YES  NO Do you drive in the day?  YES  NO With VISUAL difficulty? YES  NO Do you drive at night?  YES  NO With VISUAL difficulty?  YES  NO Do you drink alcohol?  YES  NO If YES: occasional 1 per day 2-3 /day 4+ /day Do you smoke?  YES  NO If YES: occasional ½ pack/day 1 pack/day 1+ pack Do you use street/recreational drugs?  YES  NO Are you a former user?  YES  NO Have you ever had a blood transfusion?  YES  NO Do you have now or have you ever had AIDS, ARC or HIV positive test (give date) ______ YES  NO I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member Of his staff responsible for any errors or omissions that I may have made and provided in the completion of this form

Patient Sign: ______Form completed by patient family other staff (If minor, parent/guardian signs) History reviewed No Changes Additions as noted above Reviewed by CB ______Physician’s Signature: ______John Capino, MD Date: ______