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Eye Care Professional Associates
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2017-07-06T01:14:20+00:00
Eye Care Professional Associates
Medical History Form
Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Home Phone
*
Cell Phone
Please select one:
Employed
Retired
Student
Date of Birth
*
MM slash DD slash YYYY
SSN#
*
Gender
Male
Female
Date of last eye exam:
Age
Please select one:
Single
Married
Email
If minor, name of responsible party
Relationship to minor
Primary Physician
Physician Phone
Last Medical Exam Date
Are you pregnant or nursing?
*
Yes
No
List all major surgeries, injuries, and/or hospitalizations you have had:
Do you have any allergies to medications? If yes, explain:
List any medications you currently take, including dosage and frequency:
Which pharmacy do you currently use? Please include name and location:
Please check any of the following you have had, now or in the past:
Crossed Eyes
Lazy Eye
Drooping Eyelid
Prominent Eyes
Glaucoma
Retinal Disease
Cataracts
Eye Infections
Eye Injury
Other
If other, please list:
Do you wear glasses
No
Yes
If yes, how old is your present pair of lenses?
Do you wear contacts?
Yes
No
If yes, how old is your present pair of contacts?
Type of contact lenses
Rigid
Soft
Other
Are they comfortable?
First Choice
Second Choice
Third Choice
Reason for today's visit:
Family History
Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following disease/condition
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer (specify)
Diabetes (specify)
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease (specify)
Other
Social History
This information is strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Yes I prefer to discuss the above directly with the doctor.
Yes
No
Do you drive?
Yes
No
If yes, do you have difficulty driving? If yes, please describe.
Smoking status
Never smoker
Current smoker
Former smoker
If current smoker, type/amount/how long:
Do you drink alcohol?
Yes
No
If yes, type/amount/how long:
Do you use illegal drugs?
Yes
No
If yes, type/amount/how long:
Are you sexually active?
If yes, are you currently active with:
One partner
Multiple partners
Review of Systems
Do you currently have, or have you ever had, any problems in the following areas:
Eyes (check all that apply)
Poor Vision
Eye Pain
Tearing
Redness
Jaw Pain
Scalp Tenderness
Amaurosis Fugax
Loss of vision
Blurred Vision
Double Vision
Dryness
Itching/Burning
Glare/Light Sensitivty
Flashes/Floaters
Constitutional (check all that apply)
Fever/Chills
Unexplained weight loss/gain
Ear, Nose, Throat, Mouth (check all that apply)
Stuffy Nose
Ear Ache
Cough
Dry Mouth
Cardiovascular (check all that apply)
High Blood Pressure
Rapid Heart Beat
Hematologic/Lymphatic (check all that apply)
Bleeding
Anemia
Gastrointestinal (check all that apply)
Upset Stomach
Diarrhea
Constipation
Genitourinary (check all that apply)
Burning on urination
Urinary frequency
Incontinence
Musculoskeletal (check all that apply)
Joint pains
Stiffness
Arthritis
Rheumatoid arthritis
Integumentary (check all that apply)
Rash
Changing Moles
Neurological (check all that apply)
Headache/Migraine
Seizure
Stroke
Paralysis
Psychiatric (check all that apply)
Anxiety
Depression
Insomnia
Endocrine (check all that apply)
Diabetes
Hyperthyroidism
Hypothyroidism
Allergies/Immunologic (check all that apply)
Allergies
Hay Fever
Hives
If you answered YES to any of the above or have a condition not listed, please explain & list medications:
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