Read history.pdf text version





Susskind & Almallah Eye Associates Date




Please describe any concern or problems you have with your eyes:

2 3

Do you wear : O glasses? O contact


Date of last eye exam? and Doctor? Date:_______________Doctor:_________________

10 Please give the following for the last three times you have been hospitalized. (except normal pregnancies) Reason for hospitalization Month/Yr.

4 Please check any of the problems you have with your vision or sight. O disturbance in clarity O blurred O decrease in night vision O glare or streaks around lights O halos around lights O sees flashes of light O spots before your eyes O trouble identifying colors O double vision Other_____________________________________ 5 Please list any of the problems you have with your eyes. O red or bloodshot O itching or burning sensation O eyes water a lot O discharge or pus O sensitive to light O gritty sensation O other (please name) 11 List anything you are allergic to, including medicines.

12 Review of Systems No Yes O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


6 Please check or describe problems with your eyelids. O O O O 7 eyelids itch or burn stick together in the morning red and swollen eyelids other (please describe)

Neurological _________________ Head Trauma________________ Ears, Nose, Throat____________ Respiratory__________________ Cardiovascular_______________ Hypertension________________ Gastrointestinal______________ Genituourinary_______________ Hematologic/Lymph___________ Endocrine___________________ Diabetes____________________ Musculoskeletal______________ Skin________________________ Cancer_____________________ Infectious Disease____________ Immunologic/Allergic__________ Psychiatric__________________

13 Please indicate if you or any blood Relatives have had any of the following conditions. You O O O O O O O O O O O O O Relative O O AIDS lupus/collagen dis. hepatitis emphysema/asthma diabetes or `sugar' high blood press. heart condition thyroid or arthritis cancer or tumor blindness glaucoma retinal detachment cigarette smoker

Have you ever had eye surgery? O Yes O No If yes, please describe


Have you had any eye injury? O Yes O No If yes, please describe


List all medication you are currently taking, including eye drops, birth control pills, and medications you buy without a prescription.


This form Copyright protected 2003, 2004, 2005 Susskind & Almallah Eye Assoc (updated 11/2004)

Doctors Signature______________________


1 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate


Notice: fwrite(): send of 200 bytes failed with errno=104 Connection reset by peer in /home/ on line 531