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STEP 1: Vision History

Do you now or have you ever had any of the following eye conditions?

Blurred Vision:
Itching:
Tearing:
Diabetic Retinopathy:
Eyestrain:
Eye Pain:
Wear Glasses:
Wear Contacts:
Blindness:
Dry Eyes:
Crossed Eyes:
Lazy Eye/Amblyopia:
Eye Injury:
Eye Operation:
Flashes/Floaters:
Cataracts:
Glaucoma:
Diabetes:
Detachment:
Macular Degeneration:
Frequent Eye Infections:
Discharge:
Iritis or Uveitis:
Poor Night Vision:
Night Glare:
Redness:
Double Vision:
Burning:
Sensitivity to Eye Meds:
Severe Sensitivity to Light:
Eye Disease:
Other:



If you selected 'Yes' to any of the conditions, please explain



STEP 2: Review of Systems

Do you have now or have you ever had any of the following medical conditions?


Development Delays:
Fatigue Syndrome:
Hearing Loss:
Sinusitus:
Dry Mouth:
Laryingitis:
Multiple Sclerosis:
Epilepsy:
Cerebral Palsy:
Tumors:
Stroke:
CVA:
Migraines:
Autism Spectrum Disorder:
Depression:
Attention Deficit Disorder:
Anxiety Disorder:
Bipolar Disorder:
Hypertension:
Stroke:
Vascular Disease:
Congestive Heart Failure:
Cigarette Smoker:
Bronchitis:
COPD:
Sleep Apnea:
Crohns:
Colitis:
Celiac Disease:
Ulcer:
Acid Reflux:
Prostate Disease:
STD-Herpetic:
Chlamydia:
Benign Prostate Hypertrophy:
Arthritis:
Osteoarthritis:
Fibromyalgia:
Muscular Dystrophy:
Ankylosing Spondylitis:
Osteoporosis:
Gout:
Eczema:
Rosacea:
Headaches:
Psoriasis:
Herpes Simplex:
Cold Sores:
Herpes Zoster:
Shingles:
Type 1/2 Diabetes:
Hormonal Dysfunction:
Anemia:
Blood Loss:
Ulcer:
Rheumatoid Arthritis:
Lupus:
Sjogrens:
Skin Problems:
Allergies:
Asthma:
Emphysema:
Heart Disease:
Kidney Disease:
High Cholesterol:
Cancer:
Pregnant:
Nursing:
Other:


If you selected 'Yes' to any of the conditions, please explain



STEP 3: Medication


Please list medications of any kind that you are currently taking and the dosage


Please list any known allergies or sensitivities to any medication and reaction



STEP 4: Family History

Blindness
Cataracts
Glaucoma
Other

Macular Degeneration
Retinal Disease
Crossed Eyes

Lazy Eye/Amblyopia
High Blood Pressure
Diabetes



STEP 5: Health Habits

NOTE: This information is kept strictly confidential


Do you smoke or use tobacco products?

Do you drink alcohol?

Do you use any kind of illegal drugs?

Have you ever been infected with Gonorrhea?

Have you ever been infected with Hepatitis?

Have you ever been infected with HIV?

Have you ever been infected with Syphilis?

Please indicate hobbies and interests



FINAL STEP: Signature


Patient Name *
Date of Birth *

Guardian Name