MEDICARE/MEDICAL HISTORY

New Patient_____ Former Patient______ Today’s Date______/_______/________

Name (First)______________________________(M.I)_____(Last)________________________________

Address(Street)____________________________________ City______________ State_____ Zip_______

Home Phone #___________________ Marital Status____ Spouse’s Name___________________

Birth Date _____/_____/_______ Age______ Social Security #:_________/__________/__________

Employer________________________________ Work Phone________________

Who last examined your eyes?____________________Date of Last Exam___________

Medical History

Date of Last Medical Exam_// Name of Medical Doctor:______________________

Are you allergic to any medications?If yes, please explain______________________________

List all major injuries, surgeries and/or hospitalization you have had____________________________________ _____________________________________________________________________________________

Do you wear glasses? ____No ____Yes If yes, how old is your present pair of glasses?______

Do you want a contact lens exam today?___No___Yes (Please allow 2 hours for training if this is your first time.)

Do you wear contact lenses? ____No ____ Yes Rigid___ Soft___ Extended___ Toric___ Disposable___

Are your contacts comfortable? Is your vision clear? ___No ___Yes

Review of Systems Do you currently, or have you ever had any problems in the following areas:

System NO YES NO YES

EAR NOSE THROAT

INTEGUMENTARY ___ ___ Allergies/Hay Fever ___ ___

Sinus Congestion ___ ___

NEUROLOGICAL

Headaches ___ ___ Post Nasal Drip ___ ___

Migraines ___ ___ Chronic Cough ___ ___

Seizures ___ ___ Dry Throat/Mouth ___ ___

EYES RESPIRATORY

Loss of Vision ___ ___ Asthma ___ ___

Blurred Vision ___ ___ Chronic Bronchitis ___ ___

Crossed Eyes ___ ___ Emphysema ___ ___

Glaucoma ___ ___

Loss of Side Vision ___ ___ VASCULAR/CARDIOVASCULAR

Double Vision ___ ___ Diabetes ___ ___

Dryness ___ ___ Heart Pain ___ ___

Mucous Discharge ___ ___ High Blood Pressure ___ ___

Redness ___ ___ Vascular Disease ___ ___

Sandy or Gritty Feeling ___ ___ GASTROINTESTINAL

Itching ___ ___ Diarrhea ___ ___

Burning ___ ___ Constipation ___ ___

Foreign Body Sensation ___ ___ GENITOURINARY

Excess Tearing/Watering ___ ___ Genitals/Kidney/Bladder ___ ___

Glare/Light Sensitivity ___ ___ BONE/JOINTS/MUSCLES ___ ___

Eye Pain or Soreness ___ ___ Rheumatoid Arthritis ___ ___

Infection of Eye or Lid ___ ___ Muscle Pain ___ ___

Sties/Chalazion ___ ___ Joint Pain ___ ___

Drooping Lid ___ ___

Flashes/Floaters in Vision ___ ___ LYMPHATIC/HEMATOLOGIC

Tired Eyes ___ ___ Anemia ___ ___

ENDOCRINE ALLERGIC/IMMUNOLOGIC _ _

Thyroid/Other Glands ___ ___ PSYCHIATRIC ___ ___

*PLEASE TURN FORM OVER AND COMPLETE SIDE TWO*

Please list all medications you are currently taking _______________________________________________________________ ________________________________________________________________________________________________________

Do you use tobacco products? No_ Yes_ If yes, type/amount/how long:_______________________

Do you drink alcohol? No___ Yes___ If yes, type/amount/how long:_______________________

Do you use illegal drugs? No___ Yes___ If yes, type/amount/how long:_______________________

Have you ever been exposed to or infected with ___Gonorrhea ___Hepatitis ___HIV ___Syphilis

Family History

Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions:

DISEASE/CONDITION NO YES ? RELATIONSHIP TO YOU

Blindness ___ ___ ___ __________________________________________

Cataract ___ ___ ___ __________________________________________

Crossed Eyes ___ ___ ___ __________________________________________

Glaucoma ___ ___ ___ __________________________________________

Macular Degeneratio ___ ___ ___ __________________________________________

Retinal Detachment ___ ___ ___ __________________________________________

Retinal Disease ___ ___ ___ __________________________________________

Arthritis ___ ___ ___ __________________________________________

Cancer ___ ___ ___ __________________________________________

Diabetes ___ ___ ___ __________________________________________

Heart Disease ___ ___ ___ __________________________________________

High Blood Pressure ___ ___ ___ __________________________________________

Kidney Disease ___ ___ ___ __________________________________________

Lupus ___ ___ ___ __________________________________________

Thyroid Disease ___ ___ ___ __________________________________________

Other___________ ___ ___ ___ __________________________________________

SOCIAL HISTORY This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you

prefer. ____Yes I would prefer to discuss my Social History information directly with my doctor. (Check Space)

Do you drive? ___NO ___YES If Yes, do you have a visual difficulty when driving ? ___NO ___YES

If yes, please describe _______________________________________________________________________________________________________________________________________________________________________________________________

CONSENT: I give Dr.Timothy A. Ross all authority necessary to perform diagnostic and therapeutic procedures for my best ocular health. This includes dilation, which may produce side effects and allergic reactions. Please sign below. If you are under 18 a parent or guardian must sign.

____________________________________ _______________

Patients Signature Date

Medical History

Date of Last Medical Exam_____/______/______ Name of Medical Doctor:__________________________

Are you allergic to any medications?______If yes, please explain____________________________________