Name Date. Date of Birth Age M / F Social Security No. Address City State Zip. Phone: Home Work Mobile. Occupation Employer

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Shona Jenkins
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1 Patient Information Personal Information Name Date Date of Birth Age M / F Social Security No. Address City State Zip Phone: Home Work Mobile Marital Status: Single Married Widowed Divorced Occupation Employer Driver s License Number Medicare and Private Insurance now require the next five items to be completed with your information or enter the word Declined. Weight Height Race Preferred Language Ethnicity Emergency Contact Relationship Phone Referred by: Commercial Insurance Information - Primary Insured if same as above Name of Insured Relationship Date of Birth Social Security No. Address Home Phone City State Zip Employer Business Phone Commercial Insurance (This must be completed unless you intend to pay privately) Insurance Company Subscriber I.D. # Group # Phone: Address Medicare / Medicaid Insurance Medicare # Group # Supplemental Insurance Co. Subscriber I.D. # Phone: Medicaid # Page 1

2 I. Please describe the reason for your visit today. FAMILY HISTORY II. One of the Meaningful Use requirements for using an Electronic Health or Medical Record is to include the details of your Family History. Please enter the diseases and disorders that have occurred in your immediate family. That includes your grandparents, parents, siblings and children. Disease/Disorder Relationship III. Do you take any medications? YES NO If, YES, please list names, frequency and amounts: IV. Do you have any medication or food allergies? YES NO If, YES, please list: V. Have you ever smoked? YES NO If, YES, how much currently? If you have stopped, when? VI. Alcohol? YES NO If, YES, how much? Page 2

3 Please complete the following fillable pages of your past and current history by placing a 4 mark in each box that describes your symptoms, medical problems, ocular history and review of systems. Use the Additional Details lines on page 6 to enter any explanatory text. Chief Complaint (what is your problem?) q vision change q floaters q macular pucker q blurry vision q fluctuating vision q migraines q broken blood vessel q foreign body sensation q ocular hypertension q bump on eyelid q freckle q pain in or around eye q burning sensation q glare from lights q plaquenil use q cataract q glasses problem q poor night vision q chemical burn q glaucoma q redness q chronic irritation q glaucoma suspect q routine exam q cloudy vision q gritty feelings q school request q contact lens irritation q growth on eye q second opinion q cyst on eyelid q hard to focus q shingles q diabetes q headache q skim over vision q difficult with small print q injury q stye q discharge (matter) q iritis q swelling q distorted vision q irritation q tearing q double vision q itching q trouble driving at night q dryness q keratoconus q twitching of eyelid q eyes tire easily q lids stuck together q veil or cloud in field of vision q failed driver s test q light sensitive q film over eye q long-term risk medicine q flashes of light q macular degeneration Medical History q Declines q ADD q acid reflux q acne q allergies q alzheimer s q anemia q anxiety q arthritis q asthma q autoimmune disorder q bell s palsy q bleeding tendency q blood disorder q cancer q central nervous system q cholesterol elevated q cluster headache q colitis q depression q diabetes type I q diabetes type II q diverticulitis q drug allergies q eczema q fibromyalgia q gout q hand tremor q heart disease q hepatitis q herniated disc q hypertension q irregular heart rate q kidney stones q lupus erythematosus q melanoma q migraines q multiple sclerosis q neuropathy q osteoporosis/osteopenia q parkinsonism q plaquenil therapy q prostate problem q psoriatic arthritis q respiratory problems q rheumatoid arthritis q rosacea q sarcoidosis q seizure disorder q shingles q shortness of breath q sjoegren s syndrome q sleep apnea q spine disc compression q surgery q swelling q thyroid trouble q TIA (transient ischemic attack) q tuberculosis q ulcerated colon q ulcers Page 3

4 Previous Ocular History q amblyopia q astigmatism q baggy eyelids q blepharitis q blindness q cataract q conjunctivitis q color blind q contact lens wear q corneal problem q cranial nerve palsy q crossed eyes q diabetic retinopathy q double vision q dry eyes q elevated eye pressure q farsighted q flashes of light q foreign body q freckle in eye q glaucoma q glaucoma suspect q hereditary eye condition q intraocular lens surgery q iritis q keratitis q keratoconus q lasik q macular degeneration q macular pucker q migraines q nearsighted q night vision problem q ocular migraine q presbyopia (cannot read) q pterygium q ptosis (droopy eyelid) q punctum (tearduct) plugs q recurrent erosion q radial keratotomy (RK) q retinal problem q shingles q strabismus (crooked eye) q stye q tearing q injury/trauma q vitreous detachment q wear contacts q wear glasses Cardiology q ankle swelling q atrial fibrillation q by-pass surgery q chest pain q cholesterol elevated q congestive heart failure q enlarged heart q heart disease q heart murmur q heart valve replacement q high blood pressure q irregular heartbeat q mitral valve prolapse q obstructive sleep apnea q pacemaker q palpitations q poor circulation q rheumatic fever q shortness of breath q stents q supraventricular tachycardia q syncope (fainting) Ear, Nose, Mouth and Throat History q congestion q hard of hearing q cough (dry) q head injury q cough with sputum q hoarseness q dentures q jaw claudication q dry throat/mouth q meniere s disease q dysphagia (swallowing diff) q nosebleeds q ear disorder q plugged ears q poor dentistry q runny nose q sinus problems q sore throat q sore teeth Endocrine q depression q diabetes type I q diabetes type II q diabetes type II - insulin q excessive sweating q Grave s disease q hair loss q hyperthyroidism q hypoglycemia q hypothyroidism q obesity q pancreatitis q pituitary problem q postmenopausal q thyroid problem q weight gain q weight loss Page 4

5 Gastrointestinal q acid reflux q barrett s esophagitis q black tarry stools q bloating q change in stool color q colitis q constipation q crohn s disease q diarrhea q diverticulitis q food intolerances q gastroparesis q gerd q heartburn q hemorrhoids q hiatal hernia q indigestion q irritable bowel syndrome q lazy bowel q liver trouble q nausea q use of laxatives q ulcer q vomiting Genitourinary q blood in urine q change in frequency q dsyuria (discomfort) q female disorders q genital discharge q hesitancy q high frequency of urination q high volume of urination q impotence q incontinence q kidney disease, chronic q kidney problems q kidney stones q kidney transplant q male disorders q nocturia (night urination) q prostate cancer q prostate enlargement q urgency q veneral disease Hematologic/lymphatic q anemia q bleeding tendencies q blood clots q blood disorders q blood dyscrasia q bruising tendencies q chr lymphocytic leukemia q hemochromatosis q high blood calcium q hepatitis B q lymphadenopathy q monoc gamm of unk sig q platelet disorder q sickle cell anemia q thalassemia Integumentary q acne q birth marks q cancer q change in hair or nails q change in pigmentation q cold sores of lips q dandruff q dry skin Muculoskeletal q arthritis q claudication (intermittent) q cramps q deep vein thrombosis q gout q fibromyalgia q dryness q eczema q foot sores q fungus infection q herpes simplex q lichen planis q lumps q other lesions q osteoarthritis q osteopenia q osteoporosis q pain q psoriatic arthritis q rheumatoid arthritis q poison ivy rash q pruritis (itching) q psoriasis q rosacea q seborrhea q shingles (herpes zoster) q skin rash q scleroderma q sjoegren s syndrome q swelling q systemic lupus erythematosus q varicosities Page 5

6 Neurological q alzheimer's q bell s palsy q blackouts q brain tumor q cluster headaches q dementia q dizziness q fainting q forgetfulness q guilain barré q local weakness q migraine headaches q neurodermatitis q numbness q paralysis q parkinsonism q poor coordination q poor memory q proximal muscle weakness q restless leg syndrome q seizures q speech difficulty q stroke q tingling of extremities Psychiatric q anxiety q attention deficit disorder q bipolar q dementia q depression Respiratory q asthma q emphysema q chronic bronchitis q chronic cough q chr obstruct pulmonary dis q eating disorder q manic-depressiveness q nervousness q neuroses q poor memory q cough q cough (dry) q dyspnea on exertion q orthopnea q reactive airways q psychoses q schizophrenia q sleeping difficulty q suicidal ideation q tension q shortness of breath q sleep apnea q tuberculosis Constitutional Symptoms q fever q headache q jaw claudication q malaise q night sweats q scalp tenderness Additional Details q weakness q weight gain q weight loss this form: You can click on the envelope at the top of the Adobe Reader screen to access your program and this document to rmscharf@verizon.net. Mac users: If Adobe Reader does not work with this document, the Preview application will. Page 6

PATIENT INFORMATION SSN AGE HEIGHT WEIGHT REFERRED BY

PATIENT INFORMATION SSN AGE HEIGHT WEIGHT REFERRED BY Page 1 of 5 PATIENT INFORMATION NAME ADDRESS TELEPHONE (Street) (City, State, ZIP) P Check your preferred contact number. q Home q Office q Mobile EMAIL SSN AGE HEIGHT WEIGHT GENDER q Male q Female DATE