medical history for Thurber

 

Patient Information First Name Connie Middle Initial M Last Name Deere Suffix Date of Birth 06/16/1958 Social Security Number 428-15-5245 Salutation Ms. Street Address 2095 Camp Wilkes Road City Biloxi State MS Zip 39532-4256 Country United States Address Type Home Home Phone (228)860-4637 Cell Phone (228)860-4637 Cell Phone Carrier Work Phone ()- Work Phone Extension Email connie.deere16@yahoo.com Preferred Contact Method Phone - Cell Gender F Race White Ethnicity Decline to Answer Primary Language English Nickname Marital Status Single Employer Name First Name Janessa Last Name Ullendorf Home Phone (228)669-6091 Relationship Other Work Phone ()- Cell Phone (228)669-6091

Account Responsible Information First Name Connie Middle Initial M Last Name Deere Date of Birth 06/16/1958 Social Security Number 428-15-5245 Salutation Ms. Street Address 2095 Camp Wilkes Road City Biloxi State MS Zip 39532-4256 Home Phone (228)860-4637 Work Phone ()- Work Phone Extension Email connie.deere16@yahoo.com Relationship to Patient Self

Medical Insurance Information

Referral Information Doctor Referral Patient Referral Marie Deere Newspaper Internet Search Other

Medications

Allergies

Surgeries

Ocular History Glaucoma Negative; Cataracts Negative; Macular Degeneration Negative; Eye Injury Negative; Retinal Disease Negative; Other Eye Disease Negative; Blindness/ Vision Loss Negative; Strabismus Negative; Amblyopia Negative; Ocular Complications Related to Diabetes Dry Eye Mild; Wear Glasses or Contacts yes- since 1967 Other

General History Who is your Primary Care Physician? Valerie Lenox Last Visit to PCP April Reason for Visit to PCP Well Visit/ Physical Last Eye Exam 01/10/2021 Dr Last Eye Exam Bertucci Do you work on a computer? No Hours per day

Health Review Endocrine Type 2 Diabetes - NIDDM; Hematologic/ Lymphatic Cardiovascular/ Heart Arrhythmia; High Blood Pressure Controlled; High Cholesterol; Neurological Migraines; Ears, Nose, Throat Dentures; Stuffy Nose; Respiratory/ Lungs Stomach/ Intestines Heartburn; Integumentary/ Skin Bones/ Joints/ Muscles Back Pain; Joint Pain; Muscle Pain; Allergic/ Immunologic Psychiatric Depression; Panic Episodes; Genitals/ Kidney/ Bladder Constitution Fatigue; Insomnia; Other Past Medical Conditions Details of Past Medical Conditions

Diabetic Information When were you diagnosed as diabetic? 2019 Type of Diagnosis? Diabetes Type 2 Blood Sugar Date of Last Blood Sugar // Self Monitoring Blood Sugar HbA1C HbA1C Date //

Social History Do you smoke? None Do you drink alcohol? N/A Recreational Drug Use Occupation retired teacher Hobbies reading

Family History Family History of Glaucoma Cataracts Mother; Father; Macular Degeneration Eye Injury Retina Disease Other Eye Disease Strabismus Amblyopia Blindness/ Vision Loss Diabetes Maternal Grandmother; Cancer Father; Maternal Grandmother; Heart Disease Paternal Grandmother; Paternal Grandfather; Other Family History

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