Please fill out all of the form fields as accurately as possible.

Patient History
Medical Information
Patient Name
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Date of last eye exam: (If applies to you)
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Were your eyes dilated?
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How is your general health?
Do you take medications for any of these systems?
Gastrointestinal?
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Nervous?
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Endocrine/glands?
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Ears/Nose/Throat?
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Urinary?
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Blood/Lymph?
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Cardiovascular?
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Muscles/Bones?
This field is required
Allergic/Immunologic?
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Respiratory?
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Integumentary/skin?
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Headaches?
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High Blood Pressure?
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Eyes?
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Mental?
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High Chollesterol?
This field is required
Please Explain:
Diabetes:
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Type:
This field is
Date Diagnosed:
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Allergies to medication:
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Reactions?
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Do you use Cigarettes/Tobacco or other drugs?
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Which and how often?
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Current Medication(s):
Have you had any operations?
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When?
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Name of family doctor and/or primary care physician:
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Date of last visit
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Date your blood pressure was last checked
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Family History
High Blood Pressure?
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Relation:
This field is
Macular Degeneration?
This field is required
Relation:
This field is
Diabetes?
This field is required
Relation:
This field is
Retinal Detachment?
This field is required
Relation:
This field is
Glaucoma?
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Relation:
This field is
Cataracts?
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Relation:
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Personal Eye Information
Do you have any eye conditions or problems?
This field is required
Please explain:
Have you had any eye operations?
This field is required
Kind:
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Date:
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Have you had an eye injury?
This field is required
Type:
This field is
Date:
This field is
Do you have glaucoma?
This field is required
Cataracts?
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Dry eyes?
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Macular degeneration?
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Retinal detachment?
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Blurred vision?
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Do you wear glasses?
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Contact lenses?
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Type:
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Additional Information?

Patient History Form: {{ history.first_name }} {{ history.last_name }}

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