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Watts Eye Associates
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2017-07-06T01:14:31+00:00
Watts Eye Associates
Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Date of Birth
*
MM slash DD slash YYYY
Last Eye Exam
MM slash DD slash YYYY
Name of Primary Care Physician
Occupation
Medical History
Do you have any allergies to medications?
No
Yes
Medical Allergies
Please list/explain.
List all systemic medications you currently take (including over the counter medications and vitamin supplements):
List all eye medications you currently take (including over the counter eye drops, vitamin supplements):
List all major systemic illnesses, injuries, surgeries you have had:
List any major eye injuries, eye surgeries, or eye treatments you have had:
Are you pregnant and/or nursing?
Yes
No
Do you wear glasses?
Yes
No
How old is your current lens prescription?
Do you wear contact lenses?
Yes
No
How often?
Part Time
Full Time
Over night
Do you use a computer, tablet, or smartphone?
No
Yes
Family History
Please note any immediate blood relatives, living or deceased, for the following conditions:
Blindness
Yes
No
Unsure
Relationship to you:
Lazy Eye/Eye Turn
Yes
No
Unsure
Relationship to you:
Glaucoma
Yes
No
Unsure
Relationship to you:
Macular Degeneration
Yes
No
Unsure
Relationship to you:
Retinal Detachment/Disease
Yes
No
Unsure
Relationship to you:
Eye Cancer
Yes
No
Unsure
Relationship to you:
Diabetes
Yes
No
Unsure
Relationship to you:
Other:
If applicable, please include relationship.
Social History
This information is kept strictly confidential.
Do you drive?
Yes
No
Do you wear prescription glasses while driving?
Yes
No
Do you use tobacco products?
Yes
No
Type/Amount/How long?
Do you abuse alcohol?
Yes
No
Do you use illegal/recreational drugs?
Yes
No
Type:
Have you ever been infected with/treated for:
Hepatitis
HIV
Herpes Type 1
Herpes Type 2
Lyme Disease
Review of Systems
Check any of the following medical treatments or issues that you currently have.
Constitutional
Excessive Weight Loss
Excessive Weight Gain
Neurological
Headaches / Migraines
Multiple Sclerosis
Alzheimer / Parkinson
Gastrointestinal
Crohn's Disease
Ulcerative Colitis
Eyes
Loss of Vision
Blurred Vision
Distorted Vision / Halos
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing / Watering
Glare / Light Sensitivity
Eye Pain or Soreness
Chronic Eye Infection
Styes or Chalazion
Flashes / Floaters in Vision
Ears, Nose, Mouth, Throat
Allergies / Hay Fever
Sinus Infections
Dry Throat / Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Cardiovascular
Heart / Vascular Disease
High Blood Pressure
High Cholesterol
Genitourinary
Kidney
Bones/ Joints / Muscles
Rheumatoid Arthritis
Lymphatic / Hematologic
Anemia
Leukemia
Endocrine
Diabetes Type 1
Diabetes Type 2
Hyper-Thyroid (Grave's Disease)
Hypo-Thyroid
Immune System
Immune System
Psychiatric
Anxiety Disorder
Bipolar Disorder
Depression
Schizophrenia
If you selected any of the above or have a condition not listed, please explain as needed:
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