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Bradford Optical
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2017-07-06T01:14:21+00:00
Bradford Optical
Patient History Questionnaire
Date
MM slash DD slash YYYY
Name
*
First
Last
Parent, Guardian, or Caregiver (if applicable)
First
Last
Email
Date and location of last eye exam
Main reason for today’s visit?
How did you hear about us?
Do you wear eyeglasses?
Yes
No
How old are the glasses?
Do you wear them for
Distance
Reading
Both
Do you wear contact lenses?
Yes
No
Type of contact lenses
If no, have you ever worn contacts?
Yes
No
Have you ever had any eye injury or eye operation?
Yes
No
Please describe eye injury or eye operation (with dates)
Have you been told you have cataracts?
Yes
No
Have you been told you have glaucoma?
Yes
No
Have you been told you have macular degeneration?
Yes
No
Do any relatives (mother/father/siblings) have eye problems? Please check all that apply.
Glaucoma
Macular degeneration
Lazy eye
Retinal detachment
Other eye problems not listed above
Are you being treated for any medical conditions? Please select all that apply.
Diabetes
High blood pressure
Heart disease
Depression
Anxiety
Arthiritis
High cholesterol
Thyroid disease
Other medical problems not listed above
Please list (or a give copy of) all medications that you are currently taking including vitamins, herbs and over the counter drugs
Are you allergic to any medications? Please list (or give a copy):
Name of primary care physician
First
Last
Date of last visit
MM slash DD slash YYYY
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