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College Hill Eye & Optical Center
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2019-07-03T21:57:53+00:00
College Hill Eye & Optical
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Secondary Medical Insurance
If you are covered under secondary insurance, please complete the following.
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MM slash DD slash YYYY
Phone Number
Vision Insurance Plan
Name
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Phone
Date of Birth
MM slash DD slash YYYY
Patient Health History
Although optometrists primarily treat the areas in and around the eyes, your eyes are part of your entire body. Health problems you may have, or medications that you may be taking, could affect your eyes and vision.
Primary Care Doctors Name
First
Last
Doctor's Phone Number
Date of Last Physical
Please check off all that applies to your medical health
*
Allergies
Rheumatoid Arthritis
Lupus
Diabetes
Glucose Levels
HbA1C
Thyroid Dysfunction
Hormonal Dysfunction
Fibromyalgia
Muscular Dystrophy
Osteoarthritis
Ankylosing Spondylitis
Heart Disease
High Blood Pressure
Stroke
Vascular Disease
High Cholesterol
Herpes
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Multiple Sclerosis
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Weighth Loss
Fever
Fatigue
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Anemia
Large Volume Blood Loss
Cancer
Cigarette Smoker
Asthma
Bronchitis
Emphysema
Depression
Panic Disorder
Schizophrenia
Any chance you may be pregnant?
Yes
No
Number of Children
Please list any current medications
Eyewear History, select each box that applies
Glasses
Single Vision/Reading
Bifocals
Trifocals
Progressive/No-line
Soft Contacts
Scleral
Hard/GP
Toric Soft
Disposable
Overnight Wear
Have never tried contact lenses.
Contact lenses were not comfortable when I tried them.
I would prefer or like to try colored contacts.
Would you like to try contacts that change into sunglasses?
Bifocals lens lines and head tilting is inconvenient.
Lifestyle History, check the box if your answer is yes
Work at a Computer
Would like thinner lenses
Would like to try the latest most advanced contact lenses
Spend time outdoors
Prefer not to wear glasses all the time
Family History
Ambylopia
Blindness
Cancer
Cataract
Crossed Eyes
Diabetes
Droopy lid
Eye Infections
Eye Injuries
Eye Surgery
Glaucoma
Heart Disease
High B.P.
Keratoconus
Kidney Disease
LASIK
Lazy Eye
Macular Degenration
Migraines
Retina Disease
Retina Detach
Thyroid
Social History
Computer Use
Reading
Tobacco Use
Drug Abuse
Alcohol Abuse
Student
Music
Skiing
Golf
No alcohol/drug abuse
Fishing
Tennis
Shooting
Scuba
Swimming
Biking
Non-Smoker
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