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Vision History

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

Blurred Vision:
Wear Glasses:
Wear Contacts:
Blindness:
Dry Eyes:
Crossed Eyes:
Lazy Eye/Amblyopia:
Eye Injury:
Eye Operation:
Flashers/Floaters:
Cataracts:
Glaucoma:
Retinal Disease/Tears/Detachment:
Macular Degeneration:
Frequent Eye Infections:
Tearing or Discharge:
Sensitivity to Eye Meds:
Eye Disease:
Other:


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



Review of Systems

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


Skin Problems:
Headaches:
Seizures:
Allergies:
Asthma/Bronchitis:
Emphysema/COPD:
High Blood Pressure:
Heart Disease:
Diabetes:
Kidney Disease:
High Cholesterol:
Stomach/Intestinal Problems:
Arthritis:
Blood Disorders:
Endocrine (Thyroid/Other):
Neurological Problems:
Psychological Problems:
Cancer:
Major Operations/Surgery:
Pregnant/Nursing:
Other:

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



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



Family History

Blindness
Cataracts
Glaucoma


Macular Degeneration
Retinal Disease
Crossed Eyes


Lazy Eye/Amblyopia
High Blood Pressure
Diabetes
Other



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



Signature


Patient Name *
Date of Birth *

Guardian Name