Uveitis – Specific History Form
UVEITIS – SPECIFIC HISTORY FORM
This questionnaire is to obtain facts pertinent to your past and present health. Please ANSWER ALL QUESTIONS, DO NOT LEAVE ANY BLANK. If you are not sure, guess.
Directions: Please answer each question by circling the appropriate answer either Yes or No.
Family History
(Including maternal and paternal grandparents, uncles, aunts, first cousins, mother, father, sisters and brothers.)
These questions refer to your family, NOT YOU. Questions about your own health will appear in a later section.
Has anyone in your family (not including you) had:
Tuberculosis Yes No
Arthritis Yes No
Severe anemia Yes No
High blood pressure Yes No
Sugar diabetes Yes No
Allergies Yes No
Hay fever Yes No
Asthma Yes No
Hives Yes No
Gout Yes No
Syphilis Yes No
Has anyone your family had medical troubles of the:
Eyes Yes No
Skin Yes No
Kidneys Yes No
Lungs Yes No
Intestines Yes No
Brain Yes No
Any glands Yes No
Credits: The Uveitis-Specific History Form is based on a form developed by the Francis I. Proctor Foundation.
Social History
In what states have you lived? (Please list ages and the number of years in each different state)
Have you ever lived out of the United States? Yes No
Do you take any drugs regularly? Yes No
Do you smoke? Yes No
Do you or have you ever taken Birth Control Pills? Yes No
Have you ever eaten raw meats or hamburgers? Yes No
Have you ever had a puppy (less than 3 yrs. of age)? Yes No
If so, was it de-wormed? Yes No
Have you ever had a kitten (less than 3 yrs. of age)? Yes No
If so, was it de-wormed? Yes No
As a child did you play in sandboxes frequented
by kittens or puppies? Yes No
Your Past History
Have you enjoyed good health previously? Yes No
Do you suffer from chronic disease? Yes No
Have you ever had any of the following conditions:
Cold sores Yes No
Tuberculosis Yes No
Pneumonia Yes No
Rheumatism Yes No
Arthritis Yes No
Hay fever Yes No
Asthma Yes No
Hives Yes No
Severe tonsillitis Yes No
Streptococcal infection Yes No
Severe persistent diarrhea Yes No
Severe influenza Yes No
Sugar diabetes Yes No
Scarlet fever Yes No
Skin rashes Yes No
Pleurisy Yes No
Parasitic infection Yes No
Other severe illness Yes No
Have you ever had rheumatic fever? If so, did you
Have any heart or kidney complications? Yes No
Have you ever had persistent unexplained fever? Yes No
Were you ever treated for severe anemia? Yes No
have you ever had, or were you ever treated for syphilis? Yes No
Did a doctor ever treat you for a tumor or cancer? Yes No
Have you had gonorrhea? Yes No
Has your strength been up to par for the last 5 years? Yes No
Have you had bleeding from your mouth? Yes No
from your nose? Yes No
from your lungs? Yes No
from your stomach? Yes No
from your bowel or rectum? Yes No
Do you bruise easily? Yes No
Have you been treated with X-rays? Yes No
Have you ever had any serious injuries? Yes No
Have you had any surgical operations? Yes No
If yes, please list them in order of occurrence:
Type of Operation Date
Localized Past History
Head
Do you suffer badly from frequent severe headaches? Yes No
Do you often have spells of severe dizziness? Yes No
Do you frequently feel faint? Yes No
Do you have constant numbness or tingling in any
part of your body? Yes No
Was any part of your body paralyzed? Yes No
Have you ever had a fit or convulsion? Yes No
Have you ever had a head injury? Yes No
Ears
Do you have any constant noises in either ear? Yes No
Have you ever had mastoid trouble? Yes No
Have you ever had an ear infection? Yes No
Nose and Throat
Have you ever had your tonsils or adenoids removed? Yes No
Do you have persistent hoarseness? Yes No
Are you often troubled with bad spells of sneezing? Yes No
Is your nose often stuffed up? Yes No
Have you at times had bad nosebleeds? Yes No
Do you suffer from a constantly running nose? Yes No
Have you had sinus trouble? Yes No
Have X-rays been taken of your sinuses? Yes No
Dental
Have you had your teeth examined in the past year? Yes No
Have you had teeth X-rays in the past year? Yes No
Were any teeth found to be abscessed? Yes No
Skin
Are you often bothered by severe itching? Yes No
Does your skin often break out in a rash? Yes No
Are you often troubled with boils? Yes No
Respiratory
Do you often catch severe colds? Yes No
Do you frequently suffer from heavy chest colds? Yes No
Are you troubled with constant coughing? Yes No
Have you ever coughed up blood? Yes No
Do you cough up any materials? Yes No
Have you had a chronic chest condition? Yes No
Did you ever live with anyone who had T.B.? Yes No
Do you sometimes have severe, soaking sweats at night? Yes No
Do you have bouts of chills and fever? Yes No
Gastrointestinal
Do you suffer from frequent loose bowel movements? Yes No
Have you ever had severe bloody diarrhea? Yes No
Biliary System
Have you ever had jaundice (yellow eyes and skin)? Yes No
Have you ever had serious liver or gallbladder trouble? Yes No
Do you have bilious attacks? Yes No
Bones and Joints
Are your joints ever painfully swollen? Yes No
Have your joints ever been red in color
or hot to the touch? Yes No
Do your muscles and joints constantly feel stiff? Yes No
Are you troubled with a serious bodily disability? Yes No
Do you usually have severe pains in arms or legs? Yes No
Do pains in the back make it hard for you to keep
up with your work? Yes No
Do you have a stiff back? Yes No
Do you have stiffness of muscle or joints after
inactivity or sleeping? Yes No
Genitourinary
Has a doctor ever said you have kidney
or bladder disease? Yes No
If yes to the above question, please explain:
Do you have to urinate more often than normal? Yes No
Have you ever passed blood in the urine? Yes No
Do you have burning or pain when you pass your urine? Yes No
Have you ever had a discharge from the penis? Yes No
Neuromuscular
Do you have a stiff back in the morning on awakening? Yes No
Do you have shooting or lightning pains? Yes No
Are you constantly too tired and exhausted even to eat? Yes No
Are you frequently ill? Yes No
Are you frequently confined to bed by illness? Yes No
Are you always in poor health? Yes No
Present Illness
What is your height? ft. in.
What is your usual weight? lbs.
Have you lost more than 10 pounds in the last year? Yes No
Is this the first time you have had this same type
of eye condition? Yes No
Has anyone else in your family had this same,
or a similar condition? Yes No
Have you ever known anyone with a condition
similar to yours? Yes No
X X
Patient Signature
Medical Record Audit Form
Medical Record Audit
Select 10 active patient charts with at least 3-5 prior visits: the most recent visit should have taken place within the past 6-12 months. If information should be present and is not, place an 0 in the box for that chart. If information is present, rate the quality of the information with 3 = Superior, 2 = Satisfactory, and 1 = Unacceptable. Use “NA” to score items that do not apply to a given chart (e.g., patient has no allergies).
Chart number |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Pages have patient ID | ||||||||||
| Contains biographical and/or personal data | ||||||||||
| Person providing care identified on each chart entry | ||||||||||
| Entries are dated | ||||||||||
| Entries are legible | ||||||||||
| Problem list is complete | ||||||||||
| Allergies and adverse drug reactions are prominent | ||||||||||
| Absence of allergies and reactions prominent | ||||||||||
| Appropriate past medical HX | ||||||||||
| Smoking, alcohol, or substance abuse HX documented | ||||||||||
| Pertinent HX and physical | ||||||||||
| Lab and other tests ordered as appropriate | ||||||||||
| Working diagnoses are consistent with findings | ||||||||||
| Plans of action/treatment are consistent with diagnosis(es) | ||||||||||
| Problems from previous visits addressed | ||||||||||
| Evidence of appropriate use of consultants | ||||||||||
| Evidence of continuity and coordination of care between primary and specialty physicians | ||||||||||
| Consultant summaries, lab, and imaging study results reflect primary care physician review | ||||||||||
| Completed immunization record | ||||||||||
| Prescriptions and refills noted | ||||||||||
| Med sheet used and appropriately located | ||||||||||
| Chronology maintained | ||||||||||
| Informed consent noted for all procedures and appropriate prescriptions | ||||||||||
| Patients are adequately informed (i.e., there is documentation of patient education, follow-up instructions) | ||||||||||
| Missed/canceled appointments | ||||||||||
Chart number |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Follow-up on missed/canceled appointments | ||||||||||
| Telephone calls regarding patient care noted | ||||||||||
| Charts are organized in a consistent manner internally | ||||||||||
| Transcription, if used, is accurate and physician review is noted | ||||||||||
| There is a consistent, organized format for notes (i.e., is SOAP or similar format used?) | ||||||||||
| Chart contents are securely fastened to the jacket | ||||||||||
| No inappropriate information is in the chart (e.g., subjective or personal remarks about patient, family, or other caregivers) | ||||||||||
| No inappropriate alterations or omissions (e.g., erasures, missing pages) |
Credits: The Medical Record Audit form was provided by the American Medical Association/Specialty Society Medical Liability Project.
History and Physical Form
HISTORY AND PHYSICAL FORM (Courtesy of Daniel A. Long, MD, a practicing ophthalmologist in Gretna, LA.)
Patient Name: Date: Age:
Chief Complaint: Allergy:
Meds: Beta Bl__________ 1/4 1/2 Pilo 1 2 4 Prop N25 50 D250 500
Illness: HBP IDDM NIDDM ASCVD MI CHF Asthma COPD Poor circ Thyroid
Eye History: Cataract Glaucoma CL Surgery Amblyopia
FH: Cataract Glaucoma AMD Strabismus Amblyopia
VA: sc OD 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
OS 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
cc OD 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
OS 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
REFR: OD 20/ Add: J
OS 20/ Add: J
CYCLO: OD 20/
OS 20/
STEREO: Fly Animals 1 2 3 Dots 1 2 3 4 5 6 7 8 9
COLOR: Normal Abn
EXT. OD Clear Hyperemia 1 2 3 Edema 1 2 3 Ptosis 1 2 3 mm
OS Clear Hyperemia 1 2 3 Edema 1 2 3 Ptosis 1 2 3 mm
PUPILS: OD 1 2 3 4 5 6 1+ 2+ 3+ Aff defect – 1 2 3
OS 1 2 3 4 5 6 1+ 2+ 3+ Aff defect – 1 2 3
EOM: OD Full MB:sc Ortho EP ET XP XT HP HT OD OS PD
cc Ortho EP ET XP XT HP HT OD OS PD
SLE: OD LIDS Clear Bleph Ant Post Mix 1 2 3 Pap 1 2 3 Foll 1 2 3
CORNEA Clear SPK 1 2 3 Abrasion
AC Clear C 1 2 3 F1 1 2 3 Hyph IRIS Clear PI open
LENS Clear NS 1 2 3 4 Cort 1 2 3 4 PSC 1 2 3 4 Aphakia
PC Clear 1 2 3 4
OS LIDS Clear Bleph Ant Post Mix 1 2 3 Pap 1 2 3 Foll 1 2 3
CORNEA Clear SPK 1 2 3 Abrasion
AC Clear C 1 2 3 F1 1 2 3 Hyph IRIS Clear PI open
LENS Clear NS 1 2 3 4 Cort 1 2 3 4 PSC 1 2 3 4 Aphakia
PC Clear 1 2 3 4
GONIO: OD 0 10 20 30 40 Pigm 1 2 3 4 PAS – +
OS 0 10 20 30 40 Pigm 1 2 3 4 PAS – +
OPHTH: OD Clear C/D 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 Symm Pale
Cup Shallow Med Deep
Macula NL Flat Pigm Ch 1 2 3 Drus 1 2 3 Hem Edema
MA Hem Hard ex CW NVD NVE Periph NL
OS Clear C/D 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 Symm Pale
Cup Shallow Med Deep
Macula NL Flat Pigm Ch 1 2 3 Drus 1 2 3 Hem Edema
MA Hem Hard ex CW NVD NVE Periph NL
IOP: OD 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Time
OS 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Time
IMPRESSION:
PLAN:
Informed Choice to Not Undergo Recommended Treatment or Procedure “Not Covered Benefit” (Sample Letter)
LETTER TO PATIENT REGARDING INFORMED CHOICE NOT TO UNDERGO A RECOMMENDED TREATMENT/PROCEDURE
Patient Name
Patient Address
Dear (Patient Name):
On (Date), I prescribed (Test/Procedure). On (Date), (Name of PPO, IPA, HMO) did not consider the test/procedure a covered benefit and denied payment authorization for same. On that basis, you have informed me of your decision to forego the (Treatment/Procedure) I have prescribed. I expressed my concerns regarding your decision during our discussion on (Date) about the potential ramifications of your informed choice not to undergo the (Test/Procedure).
According to my best medical judgment, I recommend that you undergo the procedure regardless of the denial of benefits by (Name of PPO, IPA, HMO). You have the right to appeal the decision of (Name of PPO, IPA, HMO) should you choose to do so.
Should you wish to discuss this further, please do not hesitate to contact me.
Sincerely yours,
(Your Name)
Informed Choice to Not Undergo Recommended Treatment or Procedure “Not Medically Necessary” (Sample Letter)
LETTER TO PATIENT REGARDING INFORMED CHOICE
Patient Name
Patient Address
Dear (Patient Name):
On (Date), I prescribed (Test/Procedure). On (Date), (Name of PPO, IPA, HMO) did not consider the test/procedure medically necessary and denied payment authorization for same. On that basis, you have informed me of your decision to forego the (Treatment/Procedure) I have prescribed. I expressed my concerns regarding your decision during our discussion on (Date) about the potential ramifications of your informed choice not to undergo the (Test/Procedure).
According to my best medical judgment, I recommend that you undergo the procedure regardless of the denial of benefits by (Name of PPO, IPA, HMO ). You have the right to appeal the decision of (Name of PPO, IPA, HMO) should you choose to do so.
Should you wish to discuss this further, please do not hesitate to contact me.
Sincerely yours,
(Your Name)
