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Eye Health Solutions – Medical History
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2018-03-28T15:11:58+00:00
Eye Health Solutions - Medical History
Medical History
Patient Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Primary Care Physician:
*
Other Physicians You See On A Regular Basis:
*
Your Pharmacy:
*
Location:
*
Have you had any bad reactions to medications or nutritional supplements?
*
Yes
No
If yes, explain:
Are you pregnant or nursing?
Yes
No
Have you had any of the following?
*
Crossed Eye (strabismus)
Lazy Eye (amblyopia)
Keratoconus
Iritis / Uveitis
Cataracts
Glaucoma
Optic nerve disease
Retinal Disease
None
Eye injury?
*
No
Yes
Which eye(s)?
Right
Left
Both
When:
Details:
Eye surgery or laser
*
No
Yes
Which eye(s)?
Right
Left
Both
When:
Details:
List all major injuries, surgeries and/or hospitalizations you have had, not related to your eyes:
*
Do you have any of these symptoms CURRENTLY?
*
Blurry vision
Double vision
Floaters blocking vision
Itching
Red eyes or lids
None
Do you have any ONGOING problems in these areas?
*
Chronic headaches
Sinus congestion
Spring / Fall allergies
Indoor allergies
Dry mouth
Loss of smell
Hearing loss
Memory loss
Dizziness
Vertigo
Chronic pain
Poor sleep
Anxiety
Depression
None
Have you been diagnosed with any of the following?
*
Migraine
Raynaud's disease
Sleep apnea
Asthma
COPD
High blood pressure
Irregular heartbeat
Congestive heart disease
Coronary artery disease
Heart valve disease
Carotid artery disease
Aneurysm
Stroke
Type 1 diabetes
Type 2 diabetes
Graves' disease
Hashimoto's thyroiditis
Other thyroid disease
Anemia
Leukemia
Lymphoma
Other blood disease
Stomach or bowel disease
Kidney disease
Hepatitis
Other liver disease
Fibromyalgia
Polymyalgia rheumatica
Giant-cell arthritis
Rheumatoid arthritis
Lupus
Sclerodema
Sjorgen's syndrome
Other autoimmune disease
Lyme disease
Severe infectious disease
Immune deficiency
Marfan's syndrome
Ehler's-Danlos syndrome
Pseudoxanthoma elasticum (PXE)
Melanoma
Skin cancer near eyes
Other cancer
Intracranial mass
Elevated intracranial pressure
Alzheimer's disease
Parkinson's disease
Multiple sclerosis
Seizures
Other neurological disease
PTSD
Mental disorder
None
List all major diagnoses NOT listed above:
*
Family History
Parents, grandparents, and siblings with the following conditions:
*
Crossed eyes (strabismus)
Glaucoma
Macular degeneration
Retinal detachment/disease
None
Social History
Do you drive?
*
Yes
No
Do you smoke?
*
Yes
No
Do you drink alcohol on a daily/weekly basis?
*
Yes
No
If you have a list of medications, please give to front desk to make a copy.
*
If not, list ALL medications you take (including oral contraceptives, aspirin, over the counter medications, alternative treatments, and nutritional supplements):
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