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Thank you for trusting us with your eye care. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to call us.

Medical History Form

Birthdate Name Gender: Male / Female

Today’s Date Primary Care

Current eye problem/symptoms? None / Routine Eye Exam Currently wear contacts? Yes / No

Details

Injury Related? If Yes, How did it occur?

PAST (Please circle all that apply or have applied for you) NONE

Anxiety Coronary Artery Hypothyroidism Arthritis Depression Leukemia Artificial joints Lung Atrial Fibrillation End Stage Renal Disease Lymphoma Asthma GERD Pacemaker / Defibrillator Yes / No BPH Hearing Loss Prostate Cancer Bone Marrow Transplantation Hepatitis Radiation Treatment Breast Cancer Seizures Colon Cancer HIV / AIDS COPD High Cholesterol Valve Replacement Other

PAST SURGICAL HISTORY (Please list all Surgical Procedures / Hospitalizations and Year) NONE

Year Year Year Year

MEDICATIONS (Please list all Allergies) NONE

(Please list all current prescription & supplements) NONE

PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU OCULAR (EYE) HISTORY(Please list eye conditions and when treated) NONE

Year Year Year OCULAR (EYE) (Please list all eye surgical procedures and when) NONE

Year Year Year

FAMILY HISTORY (Please circle all that apply and indicate relation) NONE Relation Relation Relation Cataracts Blindness Migraine Diabetes Cancer Retinal Detachment Glaucoma CVA Strabismus Macular Degeneration (AMD) Disease Other

SOCIAL HISTORY (Please check all that apply) Cigarette Smoking: Use: Illicit Drug Use: safety: Never Smoked Alcohol: None None I feel safe at home Quit: Former Smoker Alcohol: < 1 drink / day Drug use I do not feel safe at home Smokes less than daily Alcohol: 1-2 drinks / day IV Drug use Smokes daily Alcohol: 3 or more drinks / day Other

PEDIATRIC HISTORY (Complete only if child patient) Gestational Age at Birth: weeks Maternal illness during : Birth Weight: lbs oz

REVIEW OF SYSTEMS (Please circle all that apply) Eyes/Vision Cardiovascular Integumentary Poor Vision High Rash Eye Pain Rapid Heart Beat Changing Moles Tearing Redness Respiratory Neurological Jaw Pain Congestion Headache Scalp Tenderness Wheezing Seizure Amaurosis Fugax Stroke Loss of vision Paralysis Gastrointestinal G.I. Endocrine Upset Stomach Psychiatric Diabetes Diarrhea Anxiety Hyperthyroid Constipation Depression Hypothyroid Burning on Urination Urinary Frequency Constitution / System Incontinence Hematologic/Lymphatic Fever Bleeding Chills Musculoskeletal Anemia Weight Loss Joint Pain Stiffness Allergic/Immunologic ENT and Mouth Arthritis Allergies Stuffy Nose Hay Fever Ear Ache Hives Cough Dry Mouth

PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU