| Name: |
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| Todays Date: |
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| Address: |
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| City: |
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| Zip: |
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| Phone: |
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| Work Phone: |
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| Guardian (if applicable): |
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| Birth Date: |
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| Occupation: |
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| Last Eye Exam: |
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| Name of Medical Doctor: |
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| Doctors Phone: |
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| Last Medical Exam: |
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Medical History |
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| Do you have any allergies to medications? |
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| If yes, explain: |
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| List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): |
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| List all major injuries, surgeries and/or hospitalizations you have had: |
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| List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury: |
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| Are you pregnant and/or nursing? |
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| Do you wear glasses? |
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| If yes, how old is your present pair of lenses? |
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| Do you wear contact lenses? |
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| If yes, how old is your present pair of lenses? |
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| Type of contact lenses: |
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| Are they comfortable? |
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Family History\r\n\r\nPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: |
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| Blindness |
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| Relationship to You: |
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| Cataract |
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| Relationship to You: |
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| Crossed Eyes |
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| Relationship to You: |
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| Glaucoma |
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| Relationship to You: |
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| Macular Degeneration |
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| Relationship to You: |
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| Retinal Detachment/Disease |
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| Relationship to You: |
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| Arthritis |
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| Relationship to You: |
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| Cancer |
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| Relationship to You: |
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| Diabetes |
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| Relationship to You: |
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| Heart Disease |
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| Relationship to You: |
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| High Blood Pressure |
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| Relationship to You: |
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| Kidney Disease |
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| Relationship to You: |
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| Lupus |
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| Relationship to You: |
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| Thyroid Disease |
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| Relationship to You: |
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| Other: |
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| Relationship to You: |
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| Yes, I would prefer to discuss my Social History information directly with my doctor. (Check box) |
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| Do you drive? |
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| If yes, explain: |
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| If yes, explain: |
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| Do you use tobacco products? |
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| If yes, explain: |
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| Do you drink alcohol? |
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| If yes, explain: |
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| Do you use illegal drugs? |
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| If yes, explain: |
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| Have you ever been exposed to or infected with: |
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Review of Systems\r\n\r\nDo you currently, or have you ever had any problems in the following areas: |
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| Fever, Weight Loss/Gain |
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| Skin |
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| Headaches |
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| Migraines |
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| Seizures |
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| Loss of Vision |
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| Blurred Vision |
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| Distorted Vision/Halos |
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| Loss of Side Vision |
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| Double Vision |
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| Dryness |
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| Mucous Discharge |
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| Redness |
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| Sandy or Gritty Feeling |
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| Itching |
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| Burning |
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| Foreign Body Sensation |
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| Excess Tearing/Watering |
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| Glare/Light Sensitivity |
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| Eye Pain or Soreness |
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| Chronic Infection of Eye or Lid |
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| Sties or Chalazion |
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| Flashes/Floaters in Vision |
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| Tired Eyes |
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| Thyroid Disease |
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| Do you have any allergies to medications? |
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| Sinus Congestion |
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| Runny Nose |
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| Post-Nasal Drip |
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| Chronic Cough |
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| Dry Throat/Mouth |
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| Asthma |
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| Chronic Bronchitis |
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| Emphysema |
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| Diabetes |
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| Heart Pain |
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| High Blood Pressure |
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| Vascular Disease |
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| Diarrhea |
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| Constipation |
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| Genitals/Kidney/Bladder |
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| Rheumatoid Arthritis |
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| Muscle Pain |
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| Joint Pain |
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| Bleeding Problems |
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| Allergic/Immunologic |
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| Psychiatric |
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| If you answered YES to any of the above or have a condition not listed, please explain & list medications: |
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Invalid Input |
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| Anemia |
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