CIZIK
EYE
CT1tJTC
PATIENT NAME: - - - - - - - - - - - - - - - - --
DATE: ____________
Who sent you to see us today? - - - - - - - - - - - - - - - - - - - - - - What do you want us to help you with? - - - - - - - - - - - - - - - - - - - -
ARE YOU: RIGHT HANDED
0
LEFT HANDED
D
PLEASE L1 T THE NAMES and PHONE NUM BER OF YOUR H EALTH CARE PROV IDERS
Please check the box by the names of those who would like a copy of our report sent to.
0 FAMILY/PRIMARY CARE - - - - - - - - - - - - - - - - - - - - - - - - -
0
NEUROLOGIST _____________________________________________________
0 OPHTHALMOLOGIST
0 PAIN CLINIC
0 PSYCHOLOGIST/PSYCHIATRIST -------------------------------------------0 CHIROPRACTOR
0 PHARMACY
0 OTHER
MEDICAL HISTORY
Mark below any illness you have or have had
NoD Yes D ANEMIA
No D Yes D ASTHMA
No D Yes D ARTHRITIS
NoD Yes D BLOOD CLOTS
NoD Yes D CANCER
NoD Yes D DIABETES
NoD Yes D HEART DISEASE
NoD Yes D LUNG DISEASE
NoD Yes D HEPATITIS TYPE_
NoD Yes D HIGH BLOOD PRESSURE
No D Yes D HIGH CHOLESTEROL
NoD Yes D MULTIPLE SCLEROSIS
NoD Yes D RHEUMATIC FEVER
NoD Yes D SEIZURES
No D Yes D STROKE
NoD Yes D THYROID PROBLEMS
NoD Yes o SLEEP APNEA
NoD Yes D POLYCYSTIC OVARIAN SYNDROME
NoD Yes D PSYCHIATRIC PROBLEMS
(DEPRESSION I ANXIETY etc)
No o Yes 0 Other
CIZIK
EYE
C ll N I C
HAVE YOU EVER HAD A H EAD INJURY?
If yes, was there a loss of consciousness?
Yes 0
Yes 0
No 0
No 0
HAVE YOU HAD ANY PREVIOUS EYE I NJURJE / SU RGERI ES?_ _ _ _ _ __ _ _ __
IMMUNIZATIONS (Please list date)
No 0 Yes 0
Flu (date): _ _ _ _ __
No 0 Yes 0
Rubella (date): _ _ __ _ _
No 0
Tetanus (date): _ _ _ _ __
No 0
Pneumovax (date): - - - -
Yes 0
Yes 0
HOSPITALIZATION AND SURGERIES ( I NCLUDI NG EYE SURGERY)
YEAR
REASON FOR HOSPITALIZATION
PLACE
LIST ANY MED ICATIONS THAT YOU ARE CURRENTLY TAKING WITH DOSE AND FREQUENCY
(including vitamins, aspirin, eyedrops, herbals, or homeopathic remedies)
L I ST ANY DRUG ALLERGIES: - - - - - - - - - - - - - - - - - - - - - - - -
WHAT EVALUATIONS YO U HAVE HAD IN THE PAST:
TEST
APPROXIMATE DATE
LOCATION
CT
MRI
X-RAYS
BLOOD WORK
EEG, EKG, OTHER - - - - - - - - - - -- - -- - - - - - - - - - - -
SOCIAL HISTORY :
MARJTAL STATUS
OCCU PATION
HIGHEST GRADE COMPLETED IN SCHOOL _ _ _ _ _ __
ALCOHOL USE
CURREN T
PAST
YES 0
Y ES 0
NO
NO
o
o
How Much?
How Much?
TOBACCO USE
CU RRENT
PAST
Y ES o
Y ES 0
NO o
NO 0
How Much?
How Much?
STREET DRUGS
CU RRENT
PAST
YES 0
YES 0
NO
NO
o
o
How Much?
How Much?
FAM ILY HISTORY : (PLEASE LIST ANY FAMILY MEMBERS)
PROBLEM
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
FAMILY MEMBER
o
o
o
o
0
0
0
0
0
0
o
o
0
0
o
0
0
ANEMIA
ARTHRITIS
CANCER
DIABETES
DEPRESSION
EYE PROBLEMS
HEADACHES
HEART DISEASE
HIGH BLOOD PRESSURE
MULTIPLE SCLEROSIS
OBESITY
SEIZURES
STROKE
THYROID PROBLEMS
TUBERCULOSIS
BLOOD CLOTS
OTHER
REVI EW O F SYMPT OMS:
CURRENTLY OR I N T HE PAST 6 MONTH S H AVE YOU EXPERIENCED ANY OF T H E FOLLOWING?
PLEASE C H EC K NEXT TO SYMPTOM .
CONSTITUTIONAL:
No 0
Yes 0
General poor health, fevers, chills, night sweats
No 0
Yes 0
Loss of appetite
No 0
Yes 0
Feel at risk for HIV or AIDS
Yes 0
Skin rash, sores, change of a mole, lumps
SKI N:
No 0
H EAD/EARS/NOSE/THROAT:
No 0
Yes 0
Diminished hearing, tinnitus, hoarseness or sinus problems
No 0
Yes 0
Dizziness, passing out, motion sickness
No 0
Yes 0
Swallowing problems, choking
No 0
Yes 0
Sore throat, mouth, tongue
No 0
Yes 0
Change in sense of taste or smell
No 0
Yes 0
UnusuaVnew pain in temples, jaw pain when chewing, scalp pain
CARDIOVASCU L AR :
No 0
Yes 0
Chest pain or pressure, rapid or irreg ular heartbeats
No 0
Yes 0
"Blacking out" or loss of consciousness
No 0
Yes 0
Known difficulty with a heart valve, heart murmur
No 0
Yes 0
Awakening at night with shortness of breath
No 0
Yes 0
Swelling of legs or feet
No 0
Yes 0
Pain in the calves when you walk
GASTROI NTESTI NAL:
No 0
Yes 0
Heartburn, reflux, bloating
No 0
Yes 0
Frequent nausea, vomiting or stomach trouble
No 0
Yes 0
Constipation or diarrhea more than twice a month
No 0
Yes 0
Changes in bowel movement I blood in stools I other
GEN ITOURINARY:
No 0
Yes 0
Problems with urinary stream, completely emptying your bladder
No 0
Yes 0
Frequency, urgency, or urinating at night
No 0
Yes 0
Problems with leaking or burning urine, blood in urine, discharge
No 0
Yes 0
Concern regarding sexually transmitted disease
ENDOCRI NE:
No 0
Yes 0
Heat intolerance
No 0
Yes 0
Fatigued most of the time
No 0
Yes 0
Weight loss or gai n of more than 10 pounds during the last six months
No 0
Yes 0
Excess hunger, excess thirst
RESPIRATORY/SLEEP:
No 0
Yes 0
Can' t walk far or climb stairs without shortness of breath
No 0
Yes 0
Emphysema, chronic bronchitis, coughing spells, coughing blood
No 0
Yes 0
Experiencing any allergy symptoms
No 0
Yes 0
Problems falling asleep, staying asleep
No 0
Yes 0
Disruptive snoring
No 0
Yes 0
Wake yourself snoring/choking
MUSCULOS KELETAL:
No 0
Yes 0
Unusual pain, stiffness or swelling in your back, joints or muscles
PSYC HJATRJC:
No 0
Yes 0
Experiencing an unusually stressful situation
No 0
Yes 0
Experiencing excessive anxiety or hallucinations or delus ions
No 0
Yes 0
Suicidal thoughts, suicidal plans
HEME/ LYMPH :
No 0
Yes 0
Excessive bruising, bleeding
No 0
Yes 0
Enlarged glands (lymph nodes) in groins or armpits
HEIGHT:
M AXIMUM
W EIGHT _ _ _ _ _ _YEAR _
_
CU RRENT W EIGHT: _ _ _ _ __
MEN ON LY:
No 0
Yes 0
Have you used or do you use medication for erectile dysfunction
WOM EN ONLY:
Approximate date of your last mammogram. _ _ __ _ _ _ _ _ _ __
BIRTH CONTROL PILLS._ _ _ _ _ _ __
COMPLICATIONS FROM BIRTH CONTROL._ _ _ _ __
PREGNANCIES:
HOW MANY CHILDREN WERE BORN ALIVE
HOW MANY CHILDREN WERE STILLBORN _ __
HOW MANY PREMATURE BIRTHS _ _ __
HOW MANY CESAREAN SECTIONS _ __
HOW MANY M ISCARRIAGES _ _ __