Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1

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Edward M. Stroh, M.D., P.C.

 Retina Consultants of Long Island      Page 1

Please fill out completely

Legal Name

First: Middle: Last:

Address:

City: State: Zip:

Home #: Cell #: Work #:

Email:

DOB: Sex: SS #: Marital Status: M S W D

Ethnicity: Hispanic Non-Hispanic Unknown Race: Asian African American White American Indian Other

2nd Address: Type:

City: State: Zip:

Insurance Information

Primary: ID#: Relation: Self Spouse Child Other

Subscriber

DOB: SS#:

Name:

Secondary: ID#: Relation: Self Spouse Child Other

Subscriber

DOB: SS#:

Name:

Tertiary: ID#: Relation: Self Spouse Child Other

Subscriber

DOB: SS#:

Name:

Physician Information

Referred by: Phone #

Address: Primary MD: Phone # Address: Other MD: Phone # Address: Emergency Contact and/or Spouse Name: Relation:

Home #: Cell #: Work #:

Guarantor (MUST be filled out if patient is a minor!) or additional Emergency Contact

First: Middle: Last:

Address: Relation:

City: State: Zip:

Home #: Cell #: Work #:

DOB: Sex: SS #: Marital Status: M S W D

Ethnicity: Hispanic Non-Hispanic Unknown Race: Asian African American White American Indian Other I authorize the physicians and staff of Edward M Stroh, MD, PC and Retina Consultants of Long Island to dilate, test and examine my eyes to the extent necessary to determine the underlying cause of my visual difficulties and to offer possible treatment options available to me.

Patient/Guardian Signature:_______________________________________________ Date:_______________________

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Edward M. Stroh, M.D., P.C.  Patient Name: _____________________________________ DOB______________ Page 2

C

OMPREHENSIVE INFORMATION FOR OFFICE VISIT

(Chief Complaint and History of Present Illness)

(Note: If you have several problems, please ask for a separate sheet for each problem.)

What is the main retina problem that brings you to the office today?

Please describe the symptom; right eye / left eye?

When did it start? How long have you had this problem?

Did the problem come on quickly or slowly? Quickly Slowly

Please describe:

Did anything seem to cause or bring on the problem?

Is the problem always there or does it come and go? Always there Comes & goes

Is there anything that makes it better or worse? Yes No

If yes, please describe:

How severe is the problem? (You can describe how it bothers you or describe it as mild, moderate or severe.)

Has the problem changed in any way since it first came on? Yes No

Same / Better / Worse; More Often / Less Often:

Have you had this problem before or have you received a diagnosis? Yes No

If yes, please describe:

Additional Information:

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Edward M. Stroh, M.D., P.C.  Patient Name: _____________________________________ DOB______________ Page 3

M

EDICAL

H

ISTORY

Current eye medications:

V

ISION

H

ISTORY:

Past eye problems & date of onset: Past eye surgeries with dates:

P

LEASE

C

IRCLE

RT (R

IGHT

E

YE

)

OR

LT (L

EFT

E

YE

)

RT LT Lazy Eye since birth RT LT Burning

RT LT Eye glasses @ child / adulthood RT LT Feels like sand/lash in eye Date last updated: RT LT Eye Discharge

RT LT Eye Injury: Type: RT LT Tearing Eye

RT LT Blind Spot in vision RT LT Eye Redness RT LT Straight lines appear crooked/wavy RT LT Eye Pain RT LT Floating Spots/Cobwebs RT LT Itchy

RT LT Loss of side vision RT LT Matted eyes upon awakening RT LT Droopy lid RT LT Excessive light sensitivity RT LT Glare or Halos RT LT Bulging Forward of eyes RT LT Foggy/Cloudy vision RT LT Double vision

RT LT Blurring of vision: RT LT Rapid flashing lights (Strobe) Circle one or both: Distance / Near RT LT Yellow tinted vision

Do you take aspirin, Advil or other over the counter pain medicines? YES

or

NO

List:

Do you take dietary supplements or herbal supplements?

YES

or

NO

List:

Current Medications / Dosages

Associated medical condition / # of years

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R

EVIEW OF

M

EDICAL

S

YSTEMS

Circle

YES or NO if you have current problems – If Yes:  Check any specific symptoms

Nose: Yes / No Genitourinary: Yes / No Endocrine: Yes / No

Loss of Smell Sores/ulcers Palpitations

Itching / Allergies Discharge Increased Thirst

Sinus Pain Urination Weight Loss

Nose Bleeds Painful Loss of Appetite

Difficult Night Sweats

Ears: Yes / No Increased Chills

Ringing Sexually Transmitted Disease Fatigue

Hearing Loss Specify: Fever

Infection Kidney Failure

Kidney Disease Lymphatic: Yes / No Mouth: Yes / No Premature Birth of Children Tender Nodes

Ulcers / Sores Miscarriages Swollen Nodes

Jaw Cramping

Chewing Pain Musculoskeletal: Yes / No Psychiatric: Yes / No Painful to Talk Neck Stiffness / Pain Difficult Sleep Tooth Infection Lower Back Stiffness / Pain Feel Sad / Blue

Hard to Swallow Joint Pain Threatened

Joint Swelling Abused / Hurt Cardio-vascular: Yes / No Osteoporosis Alzheimer’s

Chest Pain at Rest Shoulder Ache

Chest Pain on Exertion Hip Ache Allergic: Yes / No

Faintness Arthritis Itching

Poor Circulation Specify: Sneezing

Heartbeat Skips Hand Increase Watering Eyes

Murmur Head / Hat Size Increase

High Cholesterol Known Allergies Reaction

Blood Disorder Skin / Hair / Nails: Yes / No Penicillin

Bleeding Disorder Skin Rash Codeine

Clotting Problem Skin Color Change Sulfa Drugs

Hair Increase Iodine

Respiratory: Yes / No Nail Changes Shell Fish

Breath Shortness Skin Ulcers Other:

Unable to Breathe Lying Down Tender Nodes Chest Pressure

Productive Cough Neurological: Yes / No

Bloody Spit Numbness

TB Exposure Weakness

Seizures Gastro-intestinal: Yes / No Memory Loss

Abdominal Pain Headaches

Nausea / Vomiting Head Trauma Possibly Pregnant? Yes / No

Fullness Tender Scalp Past MRSA Infection? Yes / No

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Age: Living: Medical problems or Cause of Death: Mother: _____ Y N

Father: _____ Y N Siblings: _____ Y N

_____ Y N

Please check the box for each condition that applies to your relative and indicate the relationship: F: Father M: Mother S: Sister B: Brother GP: Grandparents C: Children O: Aunts/Uncles

Check: Relative: Check: Relative:

__ Glaucoma: Diabetes:

Macular Degeneration Cancer:

Retinal detachment Heart Disease:

Retinitis Pigmentosa Stroke:

Blindness at birth

S

OCIAL

H

ISTORY

Please Circle the correct answer:

Do you drive? YES or NO

Do you drive at night? YES or NO Do you have pets or animal exposure? YES or NO

If YES, what type of animals?

Do you use tobacco products? YES or NO If YES, Type and frequency:

Call 1-800-QUITNOW for free help and information on stopping tobacco. Do you drink alcohol beverages? YES or NO

If YES, how frequently? Drinks/day?

Do you use any recreational drugs? YES or NO If YES, Type of drugs and frequency:

Do you eat undercooked meat or fish? YES or NO

MD:____________

O

CCUPATIONAL

H

ISTORY

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Name: Address:

What is/was your occupation?

Do you feel safe at home? YES or NO

Are you in a relationship in which you are being hurt or threatened emotionally or physically? Call the Domestic Abuse Hotline 1-800-500-1119 for help.

Do you have a Power of Attorney? YES or NO With Whom:_______________________________

Do you have a Do Not Resuscitate or Intubate Order? YES or NO With Whom:_______________________________

Are you currently staying in a skilled nursing facility? Yes___ No___

Name of Skilled Nursing Facility:__________________________________________________________ Address:________________________________________________ Phone #:(____)_________________ City:___________________________________________________ State:______ Zip Code:___________ PHARMACY INFORMATION:

Pharmacy______________________________________________________________________________ City __________________________________________________________State_________ Zip________ Phone #: ______________________________________Fax#:_______________________________

I have completed this medical history to the best of my ability:

P

ATIENT

S

S

IGNATURE

:

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