Name:*
Date:* |
Last eye examination:
Last
thorough
medical exam:
|
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? |
Macular Degeneration |
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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