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Salem Vision Center Medical History
admin
2019-03-11T19:25:25+00:00
Name
First
Last
Date
MM slash DD slash YYYY
Do you have any allergies to medications, dyes, foods, pollen, animals, etc.?
Yes
No
If yes, please list
List any medications you currently take (include over the counter, oral contraceptives, home remedies, vitamins, aspirin, etc.)
List any surgeries and/or hospitalizations
List any of the following that you have had: crossed eyes, drooping eyelid, protruding eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Do you use tobacco products?
Yes
No
I prefer to speak to the doctor directly
If yes, type/amount/how long
Do you drink alcohol?
Yes
No
I prefer to speak to the doctor directly
If yes, type/amount/how long
Do you use illegal drugs?
Yes
No
I prefer to speak with the doctor
If yes, type/amount/how long
Have you ever been exposed or infected with
Gonorrhea
Hepatitis
HIV
Syphilis
Do you currently or have you ever had any difficulties with the following
Fever, Weigh Loss/Gain
Headaches
Migraines
Seizures
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Double Vision
Dryness/Itching/Burning
Mucous Discharge
Redness
Sandy or Gritty Feeling
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes/Floaters
Eyestrain
Thyroid/Other Glands
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Mouth/Throat
Asthma
Chronic Bronchitis
Emphysema
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Diarrhea
Constipation
Genitals/Kidney/Bladder
Rheumatoid Arthritis
Muscle/Joint Pain
Anemia/Bleeding Problems
Psychiatric
If you answered YES to any of the above or have a condition not listed, please explain & list medications
Signature
Date
MM slash DD slash YYYY
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