Warren E. Hill, MD, FACS Neal A. Nirenberg, MD, FACS East Valley Ophthalmology, Ltd. Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology 5620 E. Broadway Road Diplomate, American Board of Eye Surgery Cataract and Comprehensive Ophthalmology Mesa, Arizona 85206-1438 Cataract and Anterior Segment Surgery Telephone: (480) 981-6111 Facsimile: (480) 985-2426 Jonathan B. Kao, MD Yuri F. McKee, MD Internet www.doctor-hill.com Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology Cataract, Cornea and External Disease Cataract, Cornea and Anterior Segment Surgery
Glaucoma Surgery and Management
Review of Systems
For new patients, established patients who may be having new problems, or patients we have not seen in a while, we need to update your overall medical health. In each area, if you are not having any difficulties please circle No problems. If you are experiencing any of the symptoms listed, please circle the ones that apply, or you may write in ones that may not be listed. If you have any questions, please ask one of our staff.
Cardiovascular Ears/Nose/Throat Musculoskeletal Respiratory Chest pain Dizziness Back pain Cough Irregular heartbeat Hearing loss Joint pain Trouble breathing Shortness of breath Hoarseness Muscle aches Wheezing ______Ringing in ears Stiffness ______Sore throat Swelling ______
No problems No problems No problems No problems
Constitutional Hematologic Neurologic Skin Fatigue Bleeding Balance problems Hair loss Fever Bruising Headache Rash Night sweats Tender nodes Numbness Skin lesions Weakness ______Tingling ______Weight loss ______
No problems No problems No problems No problems
Genitourinary Metabolic Psychiatric Allergy Genital discharge Cold intolerance Anxiety Itching Genital lesions Excess hunger Depression Hives Painful urination Excessive thirst Insomnia Runny nose Urgency Frequent urination Irritability Seasonal allergies ______Heat intolerance Nervousness ______
No problems No problems No problems No problems
Blood Pressure Control Diabetes Control Good Good Borderline Borderline Poor Poor Unknown Unknown
Not applicable Not applicable