Practice: Anthony J. Aldave, MD
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ANTHONY J. ALDAVE, MD

Cornea and Uveitis Division
Jules Stein Eye Institute


This new patient questionnaire is designed to be filled out offline. It cannot be submitted electronically at this time because of HIPAA privacy issues. Please type or print all items clearly and bring the completed questionnaire to the appointment. The information it contains will be kept in strict confidence.

                                              

Personal Information
Name
Age
Gender
Birth Date (ex.  mm/dd/yyyy)
Occupation

Referring Doctor
Name
Address
City
State
Zip Code
Phone

Your Eye Problem
Which eye is affected?
How long has the problem been present?
State briefly the problem you are having with your eye(s):

Is the problem:   

Your Medical History
List all previous surgery, including eye surgery, with dates:
List all non-surgical (medical) hospitalizations with dates:
Check any of the following problems that apply to you:
asthma emphysema kidney disease
bronchitis heart disease migraines
cancer hypertension neurologic disorders
diabetes infections thyroid problems
Other problems:
Allergies (to medicines):
none

List all medicines you currently take (pills and eyedrops):
Medicine
 Strength
(mg or % you take each time)		 Dosage
(how many pills / drops each time?)		 Frequency
(how many times per day?)		 Start Date