New Patient History Name:First Name* Last Name* MI* HiddenSection BreakSection Break1. Do you have, or have you ever had:a. Diabetes Mellitus: Yes No Diabetes Mellitus: Date of Onset and/or DetailsTreatment: Diet Control Oral Agents Insulin b. Medical Complications: Renal Neuropathy Vascular Other Medical Complications: Date of Onset and/or Detailsc. Heart Attack Yes No Heart Attack: Date of Onset and/or DetailsAngina or Chest Pain Yes No Angina or Chest Pain: Date of Onset and/or DetailsHeart Failure Yes No Heart Failure: Date of Onset and/or DetailsIrregular or Rapid Heartbeat Yes No Irregular or Rapid Heartbeat: Date of Onset and/or DetailsCardiac Pacemaker Inserted Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsd. High Blood Pressure Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailse. A Stroke or “Shock” Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsf. Anemia Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsg. Asthma Yes No Cardiac Pacemaker Inserted: Date of Onset and/or DetailsEmphysema and/or Bronchitis Yes No Cardiac Pacemaker Inserted: Date of Onset and/or DetailsPneumonia Yes No Cardiac Pacemaker Inserted: Date of Onset and/or DetailsTuberculosis Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsh. Liver Disease or Jaundice Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsi. Stomach or Duodenal Ulcer Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsj. Kidney Stones or Other Disease Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsk. Arthritis (if yes, type) Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsl. Cancer or Tumor Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsm. Thyroid Disease Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsn. Seizures or Nervous Breakdown Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailso. Varicose Veins / Blood Clots in Legs Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsp. Bleeding Disorders Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsq. Transfusions of Blood or Plasma Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailsr. TAIDS, ARC, or HIV Positive Test Yes No Cardiac Pacemaker Inserted: Date of Onset and/or Detailss. Other Medical Problems Yes No Cardiac Pacemaker Inserted: Date of Onset and/or DetailsSection BreakHave you traveled to West African countries: Guinea, Nigeria, Sierra Leone, Liberia, Sengal, or Democratic Republic of the Congo in the past 21 days? Yes No Have you been in physical contact or cared for anyone with diagnosed or suspected to have Ebola virus disease? Yes No Have you had a fever ( > 100.4 F) plus any one of the following symptoms: diarrhea, vomiting, headache, weakness, muscle pain, abdominal pain, or hemorrhaging? Yes No Section Break2. Are you allergic to any medications or to any foods? Yes No If yes, please describe the substance(s), with date and type of reaction:allergic to any medications or to any foodsSection Break3. What other medications do you take regularly?When did you last use aspirin, in any form? Section Break4. Have you had any previous eye surgery/laser, or injuries? Yes No Section Break5. What non-ocular operations have you had? Please give type(s) and date(s):Section Break6. Are you a smoker? Yes No If yes, how many cigarettes per day? If no, and you smoked in the past, when did you stop? Section Break7. Substance AbuseAlcohol? Yes No Alcohol Abuse Moderate Daily Drug Abuse? Yes No Section Break8. Have you gained or lost more than ten pounds in the past year? Yes No If yes, how many pounds have you gained? or lost? Please Explain:Section Break9. Among blood relatives, is there a history of any of the following:a. Glaucoma Yes No b. Cataracts Yes No c. "Lazy Eye" or Muscle Imbalance Yes No d. Retinal Disease Yes No e. Macular Disease Yes No f. Night Blindness Yes No g. Color Blindness Yes No h. Unexplained Vision Loss Yes No i. Diabetes Mellitus Yes No j. Tumor or Cancer Yes No k. High Blood Pressure Yes No l. Heart Disease Yes No m. Bleeding Disorder Yes No Section Break10. If applicable, are you pregnant? Yes No Section Break11. Pleae give the anme, address, and telephone number of your personal medical doctor (not your eye doctor):Doctor Name: Doctor Phone: Doctor Address: Section Break12. Please give the name, address, and telephone number of the physician that referred you to our office:Physician Name: Physician Phone: Physician Address: CAPTCHA
