NEW PATIENT QUESTIONNAIRE In order for us to better serve the needs of our new patients, we would appreciate a brief health history to assist in the examination.
Name: _____________________________ Occupation: _______________________________ E-mail: _________________________________________________________________________ How did you hear about us : ______________________________________________________ Reason for visit (please check appropriate options): Personal Medical History: Have you been treated for any one of the following medical conditions? ___ Diabetes (Type 1) ___ Diabetes (Type 2) ___ Hypertension (High Blood Pressure) ___ High Cholesterol ___ Thyroid
___ Atherosclerosis ___ Rheumatoid Arthritis
Other: ________________________________________________________________________ Are you currently taking any medications? ___ Baby Aspirin
___ Hydro Chlorothiazide Other(s): ______________________________________________________________________ Allergies to medications? Y / N If yes, then which?_______________________________ Allergies in general? Y / N If yes, then to what? _________________________________ Do you smoke? Y / N When was your last visit to your family physician? ___ Less than 1 yr
Name of family physician:_____________________________________________________
Personal Ocular History: When was your last visit to an optometrist? ___ Less than 1 yr
Name of optometrist: _________________________________________________________ Do you use a computer on a daily basis? Y /N ___Never
Have you ever worn / are you wearing contact lenses? Y / N What brand? ________________________________________________________________ Type of contact lens solution used? _____________________________________________ Any history of infections/inflammation secondary to CL wear? Y / N Have you ever had eye surgery? Y / N If yes then what type?
What was the name of the eye surgeon who performed your surgery?_______________ Have you ever had an eye injury? Y / N If yes, please describe: ____________________ _____________________________________________________________________________ Have you or a family member had any of the following eye problems/disease? ____Glaucoma
____Retinal Detachment Please specify who it is with the disease: _________________________________________ Visual Needs (please check appropriate options): ___ Work at a computer for long periods of time? ___ Have more than one pair of glasses ___ Want information on thinner, lighter lenses? ___ Wear bifocals or progressives? ___ Prefer not to wear glasses at certain times? ___ Spend a lot of time outdoors ___ Ever find a need for prescription sunglasses? ___ Have problems with glare or reflections (e.g. night driving, computer work)? ___ Do work requiring safety glasses ___ Participate in sport activities? What? __________________________________ ___ Want more information about corrective vision surgery? ___ Wear or ever tried wearing contacts? What kind?________________________ ___ Interested in coloured contact lenses? Full time? Part time? DISCLOSURE NOTICE:
All above information is for office use only and will not be used for any other purpose.
Scientific Contributions Isolated Systolic Hypertension Prognostic Information Provided by Pulse Pressure Michael J. Domanski, Barry R. Davis, Marc A. Pfeffer, Mark Kastantin, Gary F. Mitchell Abstract —Increased arterial stiffness results in increased characteristic impedance of the aorta and increased pulse wave velocity, which increases systolic and pulse pressures. An associatio
CIRCOLARE N. 2/E ______________ Roma, 28 gennaio 2011 OGGETTO : Risposte a quesiti relativi all’obbligo di comunicazione delle operazioni realizzate da soggetti passivi IVA con operatori economici black list – Art. 1 del decreto-legge 25 marzo 2010, n. 40, convertito dalla legge 22 maggio 2010, n. 73 PREMESSA . 3 1. Operazioni oggetto di comunicazione