Emory Eye Center New Patient Questionnaire

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1 Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions to the best of your ability and return the completed questionnaire to the technician or technologist when you are called. Reason for Exam (please explain): General Health (please check): appleexcellent applegood applefair applepoor Past Medical History Yes No Arthritis Asthma Cancer (please specify) Diabetes Heart Disease Hypertension Kidney Disease Skin Disease Stroke Neurologic Disorder Other Year of Diagnosis Details

2 CURRENT MEDICATIONS Please list all medications you are currently taking, or check: apple No current medications Medication Name Amount Per Day Reason ALLERGIES Please list all medications or substances to which you are allergic and specify the type of reaction, or check: apple No known allergies Allergies Reaction

3 SURGERY OR HOSPITALIZATION Surgery/ Hospitalization Year Details OCULAR HISTORY History of Eye Infection, Injury, or Surgery? apple No apple Yes Describe briefly: If the patient is a child, you must complete this section. If the patient is an adult, you may skip this section. Parent s Name: Occupation: Parent s Name: Occupation: With whom does the patient live? Who is your child s pediatrician? Name: Address: Phone: Were there any problems with your child s gestation (pregnancy), delivery, or during the first 3 months of life? appleno appleyes If yes, please describe: Has your child s growth and development been normal? appleyes appleno If no, please describe: SOCIAL HISTORY Smoke: apple Former smoker applenever smoker appleyes If yes, at what frequency? Alcohol: apple None appleyes If yes, at what frequency? Drugs: apple None appleyes If yes, please describe: Driving: apple Drives in the Daytime apple Drives at Night

4 FAMILY HISTORY Family History of Illness/Disease Details Relationship Ocular Disease Diabetes Heart Disease Hypertension Other (please explain) REVIEW OF SYSTEMS Please indicate yes or no as deemed appropriate regarding the following symptoms. If you are not sure, please leave blank NO YES Eyes Comment apple apple Blurred vision apple apple Change in vision apple apple Eye pain NO YES Constitutional/Symptoms Comment apple apple Change in weight apple apple Change in activity level apple apple Change in general health NO YES Ear, Nose, Throat & Mouth Comment apple apple Hearing problem apple apple Throat soreness apple apple Nasal drainage NO YES Cardiovascular Comment apple apple Chest pain apple apple Irregular heart beat NO YES Respiratory Comment apple apple Shortness of breath apple apple Wheezing NO YES Gastrointestinal (G.I.) Comment apple apple Abdominal pain apple apple Diarrhea apple apple Constipation apple apple Vomiting

5 NO YES Genitourinary (G.U.) Comment apple apple Pain or difficulty with urination apple apple Blood or discoloration in urine ol NO YES Musculoskeletal Comment apple apple Joint Pain or swelling apple apple Muscle pain or weakness NO YES Integumentary (Skin) Comment apple apple Rash apple apple Itching NO YES Neurological Comment apple apple Headache apple apple Dizziness apple apple Weakness or gait disturbance apple apple Numbness or tingling NO YES Psychiatric Comment apple apple Anxiety apple apple Depression apple apple Emotional changes apple apple Inconsolable NO YES Endocrine Comment apple apple Change in sleep or eating apple apple Cold or heat intolerance apple apple Abnormality in growth or development NO YES Hematologic/ Lymphatic Comment apple apple Frequent bruising or bleeding apple apple Frequent infections NO YES Allergic/ Immunologic Comment apple apple Environmental or food allergies

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