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 .