Pharmacy Intake
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2DATE ____________________
PATIENT________________________________________ CHART #_________________
PHARMACY: __________________________ Pharmacy Address: ______________________________________
MEDICAL HISTORY OR PROBLEMS FOR WHICH YOU TAKE MEDICATION
(Circle all that apply or none)
Anxiety
Depression
Leukemia
Arthritis
Diabetes
Lung Cancer
Artificial Joints
End Stage Renal Disease
Lymphoma
Asthma
GERD/Acid Reflux
Pacemaker
Atrial Fibrilation/Irregular Heartbeat
Hearing Loss
Prostate Cancer
BPH/Enlarged Prostate
Hepatitis
Radiation Treatment
Bone Marrow Transplant
Hypertension/High Blood Pressure
Seizures
Breast Cancer
HIV/AIDS
Stroke
Colon Cancer
High Cholesterol
Valve Replacement
COPD/Chronic Obstructive Pulmonary Disease
Hyperthyroidism
NONE
Coronary Artery Disease
Hypothyroidism
OTHER ____________________________________________________
PAST SURGICAL HISTORY (List any surgeries or circle none)
NONE
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
OCULAR HISTORY (Circle all that apply or none)
Allergic Conjunctivitis (Right, Left)
Glaucoma (Right, Left)
Pseudoexfoliation (Right, Left)
Blepharitis (Right, Left)
Macular Degeneration (Right, Left)
Posterior Vitreous Detachment (Right, Left)
Cataract (Right, Left)
Macular ERM (Right, Left)
Retinal Tears (Right, Left))
Corneal Dystrophy (Right, Left)
Narrow Angles (Right, Left)
Strabismus (Right, Left)
Diabetic Retinopathy (Right, Left)
Ocular Hypertension (Right, Left)
Vitreous Floaters (Right, Left)
Ophthalmic Migraine (Right, Left)
Dry Eyes (Right, Left)
Glasses, Contacts
NONE
OTHER ______________________________________________________
OCULAR SURGERY (Circle all that apply or none)
Glaucoma Laser Surgery (Right, Left)
Intravitreal Injection (Right, Left)
Lid Surgery (Right, Left)
Cataract Surgery (Right, Left)
LASIK/PRK (Right, Left)
YAG Laser / after cataract surgery
(Right, Left)
Punctal Plugs (Right, Left)
Corneal Transplant/DSAEK (Right, Left)
Retinal Laser (Right, Left)
Eye Muscle Surgery (Right, Left)
NONE
OTHER ______________________________________________________
FAMILY HISTORY (Circle all that apply and list family member or circle none)
MOTHER FATHER
OTHER
MOTHER FATHER
OTHER
MOTHER
FATHER
OTHER
Blindness
Glaucoma
Retinal Detachment
Cancer
Heart Disease
Strabismus
Cataracts
Macular Degeneration
Stroke
Diabetes
Migraine
NONE
OTHER __________________________________________
REFERRING DOCTOR: ______________________
PRIMARY DOCTOR: ________________________
FEA 2622 3_15
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