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COLUMBUS EYE ASSOCIATES MEDICAL INFORMATION SHEET- (Please answer ALL questions below)
Patient Name:____________________________________________________________ Today's Date:______________ Primary Doctor: _______________________________ Referring Doctor/Clinic: _________________________________ Physicians/Specialists you want us to send correspondence of today’s visit to:___________________________________ _________________________________________________________________________________________________ Please check any medical conditions that you have or are being treated for from the list below: ____ Diabetes(age of onset____) ____ High Cholesterol ____ Multiple Sclerosis ____ Rheumatoid Arthritis ___Meningitis __________________
Females ONLY:
Are you currently pregnant? YES or NO. If yes, please give due date: ___________________ Are you currently nursing? YES or NO
Have you ever had an eye or head injury? YES or NO? If yes, specify: _________________________________________________
Have you ever had eye surgery? YES or NO? If yes, list what type of eye surgery/laser and year performed: __________
_________________________________________________________________________________________________
Have you had any general surgeries? (DO NOT include eye surgery) YES or NO? If yes, list______________________
________________________________________________________________________________________________
FAMILY HISTORY: Please circle all of the following that apply to your immediate family (blood relatives):
UNKNOWN | NONE | Alzheimer's | Diabetes | High Blood Pressure | Cancer | Glaucoma
Macular Degeneration | Crossed Eyes | Blindness | Retinal Problems
Are you allergic to any medications? YES or NO? If yes, list the medication you are allergic to and reaction:___________
_________________________________________________________________________________________________
List current EYE Drops (Include ALL over the counter eye drops and eye supplements):____________________________
_________________________________________________________________________________________________________________________
List all of your current medications or provide copy of your current list.(Please include over the counter meds, vitamins
and supplements): _________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
***Have you ever taken Flomax (tamsulosin), Hytrin, or any bladder intolerance medications? YES or NO? *** These
medications may cause an issue with the dilation process of the pupils, even if you are no longer taking them.
Pharmacy: _______________________________ Address:__________________________________Phone#:__________________________ Do you use tobacco products? YES or NO. If yes, what type and how often?_____________________________________________ Do you consume alcohol? YES or NO. If yes, how often?________________________________________________________________ **If you are having a specific problem today with your eyes or vision, please describe the problem on the line provided below and/or check problems from the following list: _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ ____ Visual loss? (sudden or gradual change) ____ Burning sensation in the eyes? ____ Blurred vision at near? ____ Difficulty seeing when working with small

Source: http://www.columbuseyeassociates.com/Patient-Forms/Patient%20Medical%20Information.pdf

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Fakta schizofreni 1. Psykossjukdomar I Sverige insjuknar mellan 1 500 och 2 000 personer varje år i psykos varav schizofreni är den vanligaste formen. En psykos kan definieras som ett tillstånd där en persons verklighetsuppfattning är förändrad med symtom som hallucinationer, förföljelsemani, svårigheter att tänka och bristande sjukdomsinsikt. Det är oklart vad som ors

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