Patient Name:
_________________________________________
Email Address:
____________________________________ |
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1.) |
Please circle the
appropriate type of appointment that was
made:
Referral - Consult
- Personal Appointment
If a referral or
consultant, include Dr's name and reason for
appointment.
______________________________________________________________________
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2.) |
Your primary care
physician (Family Doctor) is:
_____________________________________
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3.) |
Allergies (medication or
food), & what type of allergic reaction it
caused.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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4.) |
Previous Ophthalmologist /
Optometrist:
_____________________________________
Address (if known):
________________________________________________________
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5.) |
Medical
conditions/illnesses (with or without
treatment) & year diagnosed:
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
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6.) |
Eye conditions diagnosed,
which eye(s) are involved & year diagnosed:
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
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7.) |
Previous Eye Injuries:
(type of injury, which eye, year injury
occurred):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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8.) |
Previous eye or eyelid
surgery, eye(s) or lids(s) involved, year
surgery performed, surgeon
name and location (city & state)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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9.) |
Previous major surgeries,
type of surgery, year surgery performed:
(examples: Gallbladder removed 1990,
Appendix removed 1980)
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
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10.) |
Social History:
Marital status (circle
one): Married -
Single - Divorced -
Widowed
Do you drive a motorized
vehicle (circle one): Yes -
No
Do you use or
consume the following products:
Tobacco (circle one):
Yes - No Year
started: ____
Quantity per day:
____
Alcohol (circle one):
Yes - No Year
started: ____
Use (circle one):
Light - Moderate - Heavy
Illegal Drugs (circle one):
Yes - No
Type-Amount-Frequency:
_________________________
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11.) |
Family History of eye or
medical conditions/illnesses:
(examples: glaucoma-father, diabetes-sister,
high blood pressure-mother)
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
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12.) |
Current Medications being
taken: Name - Dose - Frequency taken:
(include: over the counter meds, oral
contraceptives, vitamins & herbals)
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
___________________________________/___________________________________
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