MEDICAL HISTORY QUESTIONNAIRE NAME:________________________________________________AGE______DA TE___________________ Date of last eye exam______________Where was this done(name of Dr./Clinic)______________________ Medications(prescription,over the counter,vitamins,homeopathic):________________________________ __________________________________________________________________________________________ Are you currently on, or have you ever taken Flomax, Hytrin, Cardura, Uroxatral or Sawpalmetto? _________________________________________________________________________________________ Allergies to medications:____________________________________________________________________ List all major illnesses, injuries, surgeries:_____________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Have you ever had trauma to one or both eyes?______________________________________________ Do you currently have any problems in the following areas? If "YES" please provide information. EYES(glaucoma,cataract,retinal disease,etc.) ENDOCRINE/DIABETES (thyroid,etc.) GENERAL(fever,weight loss,fatigue,cancer) EARS,NOSE,THROAT(dry mouth,sinus,etc.) CARDIOVASCULAR(heart,high blood pressure) RESPIRATORY(asthma,emphysema,etc.) GENITAL, KIDNEY, BLADDER MUSCLES, BONES, JOINTS(arthritis, etc.) SKIN(acne,skin cancer,rashes,etc.) NEUROLOGICAL(multiple sclerosis,stroke) PSYCHIATRIC(anxiety,depression,schizophrenia) GASTROINTESTINAL(intestinal or stomach) BLOOD/LYMPH(high cholesterol,anemia) ALLERGIC/IMMUNOLOGIC FAMILY HISTORY M=Mother F=Father S=Sibling GP=Grandparent Blindness Glaucoma Macular Degeneration Diabetes Other eye disease SOCIAL HISTORY Do you drive?. Do you have visual difficulty with driving?. Do you have visual difficulty with reading?. Have you ever tried contact lenses?. Do you currently wear contacts?. Do you wear glasses?. Do you smoke?. Do you have diabetes?. History reviewed □ No changes □ Additions as noted above Patient's Signature_________________________________________Date_____________________ Physician's Signature_______________________________________Date_____________________
400 Indiana St, Suite 360 Golden, CO 80401 (303) 384-3700 Fax: (303) 384-3855
MEDICAL HISTORY QUESTIONNAIRE
_______ AGE:________ DATE:_______________ Date of last eye exam______________Where was this done(name of Dr./Clinic)______________________ Medications(prescription,over the counter,vitamins,homeopathic):________________________________ __________________________________________________________________________________________ Are you currently on, or have you ever taken Flomax, Hytrin, Cardura, Uroxatral or Sawpalmetto? _________________________________________________________________________________________ Allergies to medications:____________________________________________________________________ List all major illnesses, injuries, surgeries:_____________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Have you ever had trauma to one or both eyes?______________________________________________ Do you currently have any problems in the following areas? If "YES" please provide information. Explanation of problem M=Mother F=Father S=Sibling GP=Grandparent Relationship to Patient If yes,what is your contact lens prescription? If yes,how old are your current glasses? If yes: occasional 1/2 pack/day 1 pack/day 2 pack/day 3+ pack/day History reviewed □ No changes □ Additions as noted above Patient's Signature_________________________________________Date_____________________ Physician's Signature_______________________________________Date_____________________
400 Indiana St, Suite 360 Golden, CO 80401 (303) 384-3700 Fax: (303) 384-3855
Alzheimer’s Disease Learning Guide What it is Complications Treatment Prevention and research Caring for the AD client What it is Alzheimer’s disease (AD) is the most common form of dementia. More than 4 million Americans have AD. The disease is characterized by memory loss, language deterioration, poor judgment, and an indifferent attitude. Dementia is a brain
Agency Matters ANTS Onl ine Terms of Use THIS AGENCY MATTERS SERVICE TERMS OF USE AGREEMENT ("AGREEMENT") IS A LEGALLY BINDING AGREEMENT BETWEEN EITHER YOU OR THE ENTITY YOU REPRESENT ("YOU" AND "YOUR") AND THE PINKERMAN GROUP LLC. (" AGENCY MATTERS ," "WE," "US," OR "OUR"). BY CLICKING THE "I AGREE" BUTTON OR BY USI
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE