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Name:*
Date:* |
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Last eye examination:
Last
thorough
medical exam:
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| Do you take any medications? |
List on the next page in Section A |
| Have you had any major illnesses or injuries? |
List on the next page in Section B |
| Have you had any eye surgeries? |
List on
the next page in Section C |
| Do you have allergies to any medications? |
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Do you currently have any problems in the following areas?
If needed continue on next page in Section D |
| Eyes (poor vision, eye pain, tearing, redness, itching, burning, spots) |
N |
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| General/Constitutional (fever, heat stroke, weight loss or gain, unusually tired) |
N |
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| Ears, Nose, Throat (hard of hearing, stuffy nose, ear ache, cough, etc.) |
N |
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| Cardiovascular (high BP, racing pulse, etc.) |
N |
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| Respiratory (congestion, wheezing, shortness of breath, etc.) |
N |
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| Gastrointestinal (stomach upset, diarrhea, constipation, ulcers, etc.) |
N |
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| Genital, Kidney, Bladder (painful/frequent urination, yellow jaundice, etc.) |
N |
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| Females (Are you pregnant? Nursing?) |
N |
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| Muscles, Bones, Joints (joint pain, stiffness, swelling, cramps, arthritis, etc) |
N |
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| Skin (warts, growths, rash, skin cancer, etc.) |
N |
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| Neurological (numbness, headache, seizures, paralysis, etc.) |
N |
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| Psychiatric (anxiety, depression, insomnia) |
N |
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| Endocrine (diabetes, hypothyroid, etc.) |
N |
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| Allergic / Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.) |
N |
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Has any member of your family had these diseases (check all that apply)? And who? |
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Macular Degeneration |
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Glaucoma |
| Ever have a blood transfusion? |
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Do you drink alcohol? |
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| Do you use illicit drugs? |
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Do you smoke? |
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| Does your vision limit any activities of daily living? |
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| Patient signs:* |
Doctor signs: ________________________ |
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| Section A - Medication List |
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| Section B - Major Illnesses & Injuries |
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| Section C - Eye Surgery History |
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| Section D - Other Current Health Problems |
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