James E. Haberman, M.D., F.A.C.S.					
Excel Eye Care & Surgery Center	 						
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Historia Medica 
Historia Medica						Nombre: ____________________

Explique todas entermedades y ermegencias que usted a tenido _________________________

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Explique todas cirugias que usted a tenido___________________________________________

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Expligue todas enfermedades, ermegenciias y cirygia en ambos ojo: ______________________

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Explique todas medicinas que usted esta tomando:_____________________________________

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Es usted allerjico a alguna medicina?		___ Yes		___ No

Si, Si diga cual (s) __________________________________________________________

Review of Systems – Tiene usted algunos problemas en los preguntas debajo, Si, Si por favor de expliquar: 
								
Explique Los Problemas	

Constitutional Problems-Fever, weight loss		_________________________

Perdida de vision, vision nublada, vision cortada),		_________________________

Perdida de vision al los lado de vidion, doble vision, sequedad, o laganosos,________________	

Gos rojo, arenosos o sucios, picason, quemason o ojos cansado, ________________________

Sensebilidad a la luz, dolor o infecion,				_________________________

Dificultad viendo de noche					_________________________

Problemas de oido, naris y garganta			_________________________
 
Naris awosa, catraro, garganta seca				_________________________

Problemas de corazon					_________________________

Problemas de respiracion, bronchitis o corto de aire  ______________________

									
							Explanation of Problem 

Musculoskeletal-Arthritis					_____________________																	
Psychiatricos							_____________________ 	
	
Allerfia de temporada					_________________________	

Family History

   Disease   				Si	No		Relacion al paclente

	Glaucoma			___	___		_________________________

	Degemeracopm de macula	___	___		_________________________

	Problema de la retina		___	___		_________________________

	Arthritis				___	___		_________________________

	Diabetes			___	___		_________________________

	Alta Precion			___	___		_________________________
	
	Problema de corazon		___	___		_________________________

	Tuberculosis			___	___		_________________________

	Otra enfermedad		___	___		_________________________

Social History

Usted maneja?   		___ Si   ___ Usted fuma?   ___ Si ___ No

Usted?	___ Si   ___ No

Usted toma bebidas alcholica?	___ Si   ___ No	Si, Si con ___comidas  ___ sociable  __ otra manera   

PHYSICIAN USE ONLY

History reviewed.		___ No changes.	___ Additions as noted above.

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REVIEW OF MEDICAL HISTORY OF 			Date: 	      /          / 0

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