Sumner and Birkmann Optometrists

Name

First Middle Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Email

Date of Birth

Occupation

Referred By

Spouse's Name

Emergency Contact

Phone

What is the reason for your visit?

Name of Family Doctor?

Please list all OCULAR medications.

Please list other medications (with doses):

Are you allergic to any medications? Please list:

Reaction:

Tobacco Use?

Never Smoked
Smoker
Former Smoker

If you have quit, at what age?

Average Packs/Day?

At what age did you start?

Alcohol Use?

Yes
No

What is your average weekly intake?

Please list eye surgeries and dates.

Please list other surgeries and dates.

Please indicate if you have had any of the following:

Please list the dates of any diagnoses.

Any other medical or eye disease?

Family history of any of the above?

Review of Systems

Do you have any of the following?

Constitutional

Fever
Unexplained weight loss or gain

Ear, Nose, Throat

Decreased hearing in one or both ears
Ringing of the ears
Vertigo
Earache
Nasal discharge, nosebleeds
Hoarseness, change in voice

Cardiovascular

Pain or heavy sensation in chest
Shortness of breath on exertion
Shortness of breath that awakens you
Inability to lie flat
Swelling in feet and ankles

Respiratory

Wheezing
Cough, coughing blood
Night sweats
History of pneumonia, asthma, TB

Hematologic

Anemia
Enlarged lymph nodes
Abnormal bleeding or bruising

Allergic / Immunologic

Hay fever
Allergy to pollen, food, dander

Gastrointestinal

Change in appetite
Difficulty swallowing
Nausea or vomiting, vomiting blood
Change in bowel habits
Blood in stools or black, tarry stools

Genitourinary

Pain or burning in urination
Difficulty starting or stopping urination
Blood or pus in urine
Change in frequency of urination
Incontinence
Venereal disease
Change in menstruation

Musculoskeletal

Hot, red, swollen or stiff joints (arthritis)
Muscle pain, unexplained soreness
Pain in jaw when chewing
Scalp tenderness

Skin / Breast

Rash or hives
Change in a freckle or mole
Lumps under the skin or in the breast

Neurological

Numbness or tingling
Speech difficulties
Convulsions
Difficulty with walking, coordination
Headaches

Retinal detachment
Diabetic eye disease
Respiratory disease
Flashes or floaters
Severe eye infection
Arthritis
Amblyopia
Double vision
Eye injury
Heart disease
Cataracts
Glaucoma
Dry eyes
Cancer
Diabetes
Eye turning in or out
High blood pressure
Thyroid disease
Kidney disease
Macular degeneration