OPHTHALMIC SURGEONS AND PHYSICIANS, LTD. MEDICAL HISTORY FORM

Last Name First Name Date of Birth Glasses wearer: No Yes CL wearer: No Yes Allergies

Ocular Medications No active ocular meds No known allergies Medications Sig Description Brand Allergy Reaction

Systemic Medications No systemic meds at this time Systemic Diseases

Medications Sig Description Disease Year

Systemic Surgical History Social History Surgery Year Outcome Smokes: Alcohol: No Yes No Yes Formerly Formerly Caffeine: Drug use/abuse: No Yes No Yes Formerly

Past Ocular History No past ocular history noted Pt has prosthetic Right eye Left eye Category Disease Eye When Procedure Eye When

Family History No relevant family history Adopted Vitals

Family Member Y/N Diagnosis Date Height Ft Height In Weight Lb

Blood Sugar

BS BS Date Time Taken A1C A1C Last Ckd

Page 1 of 2 MEDICAL HISTORY FORM

Last Name First Name Date of Birth Review Of Systems Constitutional Cardiovascular Metabolic/Endocrine Neg Pos Neg Pos Neg Pos fatigue arrhythmia cold intolerance fever calf pain heat intolerance night sweats chest pressure or discomfort polydipsia weakness irregular heartbeat/palpitation polyphagia weight gain leg swelling polyuria weight loss tachycardia Other positives: Other negatives: Other positives: Other negatives: Other positives: Other negatives:

Integumentary HEENT Neg Pos Neg Pos Neg Pos Neg Pos abnormal hair dist. skin changes exophthalmos sore throat dry skin skin lesion hearing loss tinnitus hives skin nodules hoarseness vertigo itching skin skin sores lump in neck nail changes ulcer nasal congestion rash sinus problems Other positives: Other negatives: Other positives: Other negatives:

Gastrointestinal Neurological Neg Pos Neg Pos Neg Pos abdominal pain food intolerance balance disturbances black tarry stools heartburn dizziness constipation increased appetite focal weakness decreased appetite jaundice headache diarrhea nausea memory difficulty dysphagia vomiting numbness of extremities Other positives: Other negatives: Other positives: Other negatives:

Musculoskeletal Respiratory Genitourinary Neg Pos Neg Pos Neg Pos Neg Pos arthralgias joint stiffness asthma dysuria back pain joint swelling cough genital lesions fracture muscle cramping dyspnea hematuria gait disturbance muscle weakness dyspnea on exertion irregular menses Other positives: Other negatives: hemoptysis urethral discharge wheezing urgency Other positives: Other negatives: Other positives: Other negatives:

Psychiatric Hematologic / Lymphatic Immunologic Neg Pos Neg Pos Neg Pos Neg Pos depressed mood insomnia bleeding environmental allergies emotional changes irritability bruising food allergies euphoria nervousness lymphadenopathy seasonal allergies frequent nightmares stress tender lymph nodes hallucinations Other positives: Other negatives: Other positives: Other negatives: Other positives: Other negatives: Page 2 of 2