PALO ALTO EYE GROUP
1805 EL CAMINO REAL, SUITE 100 • PALO ALTO, CA • 94306
5150 GRAVES AVENUE, BUILDING 2 • SAN JOSE, CA 95129
PHONE: 650.324.9200 • FAX: 650.326.5793
PATIENT HISTORY
Name ________________________________________________
Date ________________
PAST MEDICAL HISTORY
Please check all that apply:
____
____
____
____
____
Diabetes
Heart Disease
Stroke
High Blood Pressure
High Cholesterol
____
____
____
____
____
Asthma
Emphysema
Cancer
Arthritis
Thyroid Disease
____
____
____
____
____
Glaucoma
Cataracts
Macular Degeneration
Crossed Eyes
Lazy Eyes
____ Other (please list) _________________________________________________________
_____________________________________________________________________________
List any operations you have had __________________________________________________
_____________________________________________________________________________
MEDICATIONS
List any medications you currently take _____________________________________________
_____________________________________________________________________________
ALLERGIES
Do you have allergies to any medications?
____ Yes
____ No
If yes, list medications ___________________________________________________________
______________________________________________________________________________
FAMILY HISTORY
Disease
Yes
No
Relationship to Patient
Glaucoma
Retinal Detachment
Diabetes
Other ________________________
___
___
___
___
___
___
___
___
________________________________
________________________________
________________________________
________________________________
OVER
REVIEW OF SYSTEMS
Do you currently have any problems in the following areas? If “yes”, provide information.
Constitutional Symptoms
Fever
Weight loss
Eyes
Loss of vision
Blurred vision
Double vision
Dryness
Redness
Sandy feeling
Itching
Tearing/watering
Glare/light sensitivity
Prominent eyes
Ears, nose, throat
Sinus congestion
Runny nose
Cardiovascular
Chest pain
Swelling of ankles
Respiratory
Shortness of breath
Cough
Gastrointestinal
Nausea
Diarrhea
Genitourinary
Kidneys
Bladder
Musculoskeletal
Joint pain
Neurologic
Headache
Psychiatric
Yes
No
Explanation of Problem
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
SOCIAL HISTORY
Current Occupation _____________________________________________________________
Do you have visual difficulty when driving?
___ Yes ___ No
Do you smoke or have you ever smoked?
___ Yes ___ No
If yes, how many packs per day and for how long?
________________________________
Do you drink alcohol daily?
___ Yes ___ No
If yes, how many drinks per day?
________________________________
Name ________________________________________________
Date _______________