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Birthdate:
Date of last eye exam:
Name of medical doctor:
Doctors Phone:
Date of last medical exam:
Do you have allergies to medications?
Ye
No
If yes, Explain:
List any medications you take
List all major, surgeries, or hospitalizations you have had:
Check box for all that you have had
Crossed eyes
Lazy eye
Drooping eyelid
Prominent eyes
Glaucoma
Retinal disease
Cataracs
Eye infection
Eye injury
Are you pregnant / nursing?
Yes
No
Do you wear glasses?
Yes
No
Do you wear contact lenses?
Yes
No
Are they comfortable?
Ye
No
I do not wear contact lenses
Family History (Check all that apply)
Blindness
Cataract
Crossed eyes
Glaucoma
Macular Degeneration
Retnal Detachment / Desease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupas
Thyroid Disease
If you checked any box above, list what and how they are related to you. Example: Blindness - Father
Do you drive:
Yes
No
If yes, do you have visual difficulty when driving?
Yes
No
If yes, Please explain:
Do you use tobacco or alchol products?
Ye
No
Type / Amount / How long?
Do you use illegal drugs?
Yes
No
Type / Amount / How long?
Have you ever been exposed or infected with:
Gonorrhea
Hepititas
HIV
Syphilis
Review of symptoms: CONSTITUTIONAL
Fever
Weight gain / Weight loss
Review of symptoms: INTEGUMENTARY
Skin Problems
Skin Problems
Review of symptoms: EYES
Loss of vision
Blurred vision
Distorted vision (halos)
Loss of side vision
Double vision
Dryness
Mucus discharge
Redness
Sandy or Gritty feeling
Itching
Burning
Forign body sensation
Excess tearing / watering
Glare / Light sensitivity
Eye pain or soreness
Chronic Infection of eyelid
Sties or Chalazion
Flashes / Floters in vision
Tired eyes
Review of symptoms: ENDOCRINE
Thyroid / other glands
Second choice
Review of symptoms: EARS, NOSE, MOUTH, THROAT
Allergies / Hay fever
Sinus congestion
Runny nose
Post-nasal drip
Chronic caugh
Dry throat / mouth
Review of symptoms: RESPIRATORY
Asthma
Chronic Bronchitis
Emphysema
Review of symptoms: VASCULAR / CARTIOVASCULAR
Diabetes
Heart pain
High blood pressure
Vascular disease
Review of symptoms: GASTROINTESTINAL
Diarrhea
Constipation
Option 3
Review of symptoms: GENITOURINARY
Genitals / Kidney / Bladder
Second choice
Review of symptoms: BONES / JOINTS / MUSCLES
Rheurnatiod arthritis
Muscle pain
Joint pain
Review of symptoms: LYMPHATIC / HEMATOLOGIC
Anemia
Bleeding Problems
Review of symptoms: ALLERGIC / IMMUNOLOGIC
Immune Problems
Second choice
Review of symptoms: PSYCHIATRIC
Psychiatric Problems
Second choice
If you selected yes for any of the above problems or you have a problem that is not listed here, Please explain, and list medications.
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