AEC Rev Intake Form

Transcript

1 Alberta Eye Care New Patient Questionnaire Thank you for visiting our office. At Alberta Eye Care, we take great care to make sure we provide you with the highest level of in g of your healthcare service. To assist us in the providing you with the best care possible, we need to have a comprehensive understand swers will personal and family health history. Please fill out the questionnaire with the best information that you can provide. Your an ...a nd we take that confidential and will not be shared or sold at any point, as we are bound by HIPAA to protect your priv remain acy stuff seriously! _________ ___________________________ (circle): Mr. Mrs. Ms. Miss. Dr. PATIENT NAME _____ O Employer _______________ ccupation ________________ __________________ - mail address ____________________________________ Nickname E ______ at (Clinic or Doctor)________________________ Year of last eye exam ____ Have you previously had eye surgery, including LASIK, PRK or RK ? Yes / No List your general medical doctor, his/her clinic and phone number Dr. _______________________________ ______________________________ phone _____________________ at YOUR Tell us about health. Do you have any of the conditions listed below? List any current medications (prescribed or over the counter) or treatments, even if unrelated to the eyes. Yes No List Medications or Treatments Are you: (please circle) ________ ___ ___ __________________________ Pregnant/breastfeeding No Yes Cancer, type ______ ENT: Sinus, throat, hearing loss, etc ___ ___ Allergic to latex? No Yes __________________________ Yes ___ ___ Neuro: Epilepsy, stroke, migraine o medications No __________________________ Allergic t Psychiatric: Anxiety, depression, etc ___ ___ __________________________ If yes, please list below: Cardiovascular: High blood pressure ___ ___ __________________________ high cholesterol, heart condition ___ ___ ___________ _______________ tory : As ___ ___ __________________________ Respira thma, sleep apnea : Ulcer, Crohns, Celiac ___ ___ __________________________ G I U : Kidney disease, prostate, STD ___ ___ __________________________ G ___ ___ Musculoskeletal: Arthritis, __________________________ ___ ___ fibromyalgia __________________________ Skin: Eczema, rosacea, herpes, etc ___ ___ __________________________ Endocrine: Diabetes, thyroid, __________________________ ___ ___ birth control, hormones ___ __ _ __________________________ Hematologic : anemia ___ ___ __________________________ Immune: Lupus, seasonal allergies ___ ___ __________________________ ___ ___ Other_____________________ __________________________ ___ I do not have any of the above, or other health conditions, or take any medications. ? (please circle): Yes / No If yes, how many drinks per week? ________ Do you drink alcohol ? (please circle): Yes Not now Never If yes, how do you smoke and how often? ____________________ Do you smoke Height ______________________ Weight _____________________ Preferred language Ethnicity (please circle): Hispanic or Latino Not Hispanic or Latino : _________________________ Race (please circle): White/Caucasian Black/African American Indian: Continent of India American Indian/Alaska Native Asian Native Hawaiian or other Pacific Islander Other race: __________

2 SIDE 2. PATIENT NAME ________________________________ FAMILY health. Has anyone in your family had any of the conditions listed below? Tell us about your Family Member No Yes ___________ ___ ___ Cancer, type ______________ ________ ___________ ___ ___ Cardiovascular: High blood pressure ________ ___________ ________ high cholesterol, heart condition ___ ___ ________ ___________ Endocrine: Diabetes, thyroid, ___ ___ Other_____________________ ___ ___ has had these or other eye conditions? Please list which family member. Has anyone in your FAMILY Family Member No Yes ________ ___________ Cataracts ___ ___ ________ ___________ ___ ___ Macular degeneration ___ ___ Glaucoma ___________ ________ Crossed or lazy eye ________ ___________ ___ ___ ___ ___ ________ Blindness (even later in life) ___________ ________ ___________ ___ ___ Other_____________________ PHR Interview Questions ___________________________________________________________ What is your reason for visiting us today? Have YOU ever been diagnosed with any of the following conditions? No Yes Cataracts ___ ___ ___ ___ Dry eye ___ ___ allergy ___ ___ Macular degeneration Eye infection, inflammation, or ___ ___ Glaucoma ___ ___ Floater, and/or flashes of light Diabetes ___ ___ Iritis or uveitis ___ ___ Diabetic retinopathy ___ ___ Retina defects or degenerations ___ ___ Other _____________________ _________ ______________________ Are you having any of the following eye/vision concerns? Yes No No Yes Eye pain ___ ___ ___ ___ Redness Severe sensitivity to lights ___ ___ Burning ___ ___ Headache ___ ___ ___ ___ Itching ___ ___ Tearing ___ ___ Poor night vision Discharge Bothersome night glare ___ ___ ___ ___ ___ ___ ___ ___ Blurred vision Double vision ___ ___ Eyestrain ___ ___ Total loss of vision Other ______________________________________________ ______ What are you mainly using for distance vision activities? No Correction Eyeglasses Contact Lenses (CL) Describe the quality of your distance Acceptable May Need Improvement Blurred vision activities: What are you mainly using for vision activities? No Correction Eyeglasses Contact Lenses CL & Readers near/reading Describe the quality of your near/reading vision activities: Acceptable May Need Improvement Blurred CL & Readers What are you mainly using for vision activities? No Correction Eyeglasses Contact Lenses computer Describe the quality of your computer vision activities: Acceptable May Need Improvement Blurred

Related documents

HANDBOOK of METAL ETCHANTS

HANDBOOK of METAL ETCHANTS

HANDBOOK of METAL ETCHANTS Editors Perrin Walker William H. Tarn CRC Press Boca Raton Boston London New York Washington, D.C. © 1991 by CRC Press LLC

More info »
Operator Directory Listing

Operator Directory Listing

OPERATOR'S DIRECTORY SORTED BY OPERATOR NAME DATA SUPPLIED BY: FORM 1006 B CURRENT AS OF: Tuesday, April 16, 2019 Please notify Surety Department at ( 405 ) 521-2273 of any corrections or omissions th...

More info »
Implementation Handbook For The Convention On The Rights Of The Child

Implementation Handbook For The Convention On The Rights Of The Child

IMPLEMENTATION HANDBOOK FOR THE CONVENTION ON THE RIGHTS OF THE CHILD FULLY REVISED THIRD EDITION IMPLEMENTATION HANDBOOK IMPLEMENTATION HANDBOOK FOR THE CONVENTION ON THE FOR THE CONVENTION ON THE RI...

More info »
CalCOFI Atlas 33

CalCOFI Atlas 33

THE EARLY STAGES IN OF THE FISHES CALIFORNIA CURRENT REGION CALIFORNIA FISHERIES COOPERATIVE OCEANIC INVESTIGATIONS ATLAS NO. 33 BY THE SPONSORED STATES OF COMMERCE DEPARTMENT UNITED OCEANIC AND ATMOS...

More info »
Experimental and Theoretical Statics of Liquids Subject to Molecular Forces Only

Experimental and Theoretical Statics of Liquids Subject to Molecular Forces Only

EXPERIMENTAL AND THEORETICAL STATICS OF LIQUIDS SUBJECT TO MOLECULAR FORCES ONLY, BY J. PLATEAU Professor of the University of Ghent, Member of the Academy of Belgium, Correspondent of the Institute o...

More info »
FastLane Help

FastLane Help

FastLane Help FastLane Help 1

More info »
Capital Volume I

Capital Volume I

Capital A Critique of Political Economy Volume I Book One: The Process of Production of Capital First published: in German in 1867, English edition first published in 1887; Source: First English editi...

More info »
Multi Project Instructions for NIH and Other PHS Agencies

Multi Project Instructions for NIH and Other PHS Agencies

VERSION E SERIES FORMS 25, 2017 Released: September December Revised: 2018 7, PROJECT INSTRUCTIONS FOR MULTI - AND OTHER PHS AGENCIES NIH SF424 (R&R) APPLICATION PACKAGES NIH and maintained by Guidanc...

More info »
PB

PB

OFFICIAL 2019 CONNECTICUT PRACTICE BOOK (Revision of 1998) CONTAINING RULES OF PROFESSIONAL CONDUCT CODE OF JUDICIAL CONDUCT RULES FOR THE SUPERIOR COURT RULES OF APPELLATE PROCEDURE APPENDIX OF FORMS...

More info »
Motor Vehicle Title Manual

Motor Vehicle Title Manual

M OTOR V EHICLE T ITLE M ANUAL TxDMV April 2019

More info »
Application Submission System & Interface for Submission Tracking (ASSIST) User Guide

Application Submission System & Interface for Submission Tracking (ASSIST) User Guide

Application System & Submission Interface Submission Tracking for (ASSIST) User Guide System Version 2.28.0 Document Version 6.6.2 January 30, 2018

More info »
Numerical Recipes

Numerical Recipes

Sample page from NUMERICAL RECIPES IN C: THE ART OF SCIENTIFIC COMPUTING (ISBN 0-521-43108-5) Permission is granted for internet users to make one paper copy for their own personal use. Further reprod...

More info »
AndersBehringBreivikManifesto

AndersBehringBreivikManifesto

2011 , London – By Andrew Berwick

More info »
LawReferenceBook2018

LawReferenceBook2018

California Contractors License Law & Reference Book 2018 Edition With Rules and Regulations Contractors State License Board State of California Edmund G. Brown, Jr., Governor

More info »
book.dvi

book.dvi

Convex Optimization

More info »
Fannie Mae 2017 Form 10 K

Fannie Mae 2017 Form 10 K

UNITED ST ATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 Form 10-K O SECTION 13 OR 15(d) ANNUAL REPORT PURSUANT T ACT OF 1934 OF THE SECURITIES EXCHANGE For the fiscal year ended Decem...

More info »
FAST Act Modernization and Simplification of Regulation S K

FAST Act Modernization and Simplification of Regulation S K

Conformed to Federal Register version SECURITIES AND EXCHANGE COMMISSION 17 CFR Parts 229, 230, 232, 239, 240, 249, 270, 274, and 275 10618; 34 -85381; IA -5206; IC [Release No. 33- File No. S7 -08- 1...

More info »
Medicare

Medicare

Department of Health and Human Services (DHHS) Medicare Centers for Medicare and Provider Reimbursement Manual Medicaid Services (CMS) Part 2, Provider Cost Reporting Forms and 10 - Instructions, Chap...

More info »