PATIENT MEDICAL INFORMATION AND HISTORY

PATIENT MEDICAL INFORMATION AND HISTORY
KARTESZ EYE CARE
Name:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
Date:*
Date Format: MM slash DD slash YYYY
OCULAR HISTORY
Do you now or have you ever had any of the following disorders?
Glaucoma*
Cataracts*
Corneal Disease*
Macular Degeneration*
Macular Degeneration*
Retinal Disease or Detachment*
Optic Nerve Disorders*
Other:
Have you ever had eye surgery?*
If Yes, Please Explain:
Which eye did you have surgery on?
When:
OCULAR FAMILY HISTORY
Please note any FAMILY HISTORY (Parents, Grandparents, siblings, children; living or deceased) for any of the following conditions:
Glaucoma*
Cataracts*
Macular Degeneration*
Retinal Disease or Detachment*
Blindness*
Other:
MEDICATIONS
Please list all medications you are currently taking:
Ocular/Eye:
Systemic/Other:
Please List Any Drug Allergies:
GENERAL HEALT HISTORY:
Do you have or have you ever had the following disorders?
High Blood Pressure/Hypertension*
High Cholesterol*
Heart Disease*
Heart Murmur*
Hardening of the Arteries*
Stroke*
Chronic Cough*
Allergies/Hay Fever*
Sinus Congestion*
Diabetes*
Thyroid Disorder*
Gastrointestinal Disorders*
Kidney Disease*
Anemia*
Blood Disorder*
Immunodeficiency*
Lyme Disease*
Skin Disorders*
Arthritis*
Muscle Pain*
Joint Pain*
Headaches*
Seizures*
Psychiatric (Depression/Anxiety)*
Asthma*
COPD*
Are you currently Nursing or Pregnant?
Thank you.