Stephan Jankowski O.D. 93 S. Morse St. Sandusky, MI 48471 (810) 648-2456
Medical History Form |
Patient Information Forms:
Please print out the the Patient information page and the Medical History page (below). Fill in the blanks and bring them with you at the time of your appointmentOCULAR AND MEDICAL HISTORY QUESTIONNAIRE – REVIEW OF SYSTEMS
Name __________________________________ Date _________________
OCULAR HISTORY
Yes No Yes No
____ ____ Cataracts ____ ____ Corneal Disease
____ ____ Retina Disease ____ ____ Glaucoma
____ ____ Crossed Eyes ____ ____ Eye Injury
____ ____ Iritis ____ ____ Macular degeneration
____ ____ Spots or Floaters ____ ____ Double Vision
____ ____ Do you presently wear glasses? ____ ____ Do you presently wear contacts?If so, how old are your current glasses / contact lenses _____________________________
____ ____ Are you currently using eye drops? If so, what kind of eye drops are you using?
Date of last vision Exam: __________________________ Where?_____________________Date of Cataract surgery? Right eye ___________ left eye _______________ Do you have implants? ____________
Any Other eye disorders?_____________________________________________________________
Explanation of Eye Injury _____________________________________________________________________
Any problems seeing at distance?____ Night Vision? ____ Driving? ____ T.V.? ____ Movies? ____ How Long?_____
Any problems focusing at close range? ____ Reading? ____ Sewing? _____ Computer? _____ Phone Book? ______
Do your eyes burn? _____ Ache? ____ Tire?____ Itch? ____ Water? ____
GENERAL MEDICAL HISTORY
____ ____ Asthma ____ ____ Head or Spinal injury
____ ____ Kidney disease ____ ____ Seizures, convulsions
____ ____ Tuberculosis ____ ____ Cancer
____ ____ Diabetes # of years________ ____ ____ Thyroid disease
____ ____ Insulin dosage ____ # of years _____ ____ ____ Temporal arteritis
____ ____ Migraines ____ ____ Arthritis
____ ____ Psychiatric disorder ____ ____ Carotid artery disease
____ ____ Nervous Disorder ____ ____ Heart Disease
____ ____ High Blood Pressure ____ ____ Ulcer
____ ____ (Women) are you pregnant? ____ ____ Stroke
____ ____ Anemia ____ ____ HIV
____ ____ Confinement by illness/injury ____ ____ Any other disease _________
____ ____ Permanent defect from illness/injury
Other Health problems or surgeries: ___________________________________________
List all current medications you are taking (including Birth control pills, hormone replacement or over counter medications):__________________________________________________
_____________________________________________________________________
List Medications or other items you are allergic to: _________________________________
_____________________________________________________________________
FAMILY HISTORYHas anyone in your family (blood relative) had any of the following in the past?
____ ____ Glaucoma ____ ____ Diabetes
____ ____ Cataracts ____ ____ Heart Disease
____ ____ Corneal disease ____ ____ Diabetic retinopathy
____ ____ Macular degeneration ____ ____ Retinal detachment
____ ____ Retinitis pigmentosa ____ ____ Stroke
____ ____ Other eye problems _______________________________________________SOCIAL HISTORY
Use of alcohol Never ____ Rarely ____ Moderate ____ Daily ____
Use of Tobacco Never ____ Currently # of packs per day _______ Previously but quit ____Use of Drugs Never ____ Type / frequency_______________________________________
Excessive exposure at work or home to: Fumes ____ Dust ____ Solvents ____ Air-borne particles ____ Noise ____