Download HEALTH HISTORY AIDS/HIV Yes Yes Lazy Eye Yes Yes Arthritis

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HEALTH HISTORY
Please complete both front and backsides of this form
Patient’s Name____________________________ Birth Date______________________________
Family Physician________________________(M.D or D.O.) Physician Family Address____________________
City___________________ State______________ Zip Code_____________ Phone Number_________________
Please circle to indicate if you have had any of the following. Also please circle to indicate if a blood relative
has had any of the following problems.
Yourself Family
AIDS/HIV
Arthritis
Asthma
Cancer
Chemical Dependency
Diabetes
Drug Sensitivity
Emphysema
Heart Disease
Hepatitis(Type____)
High Blood Pressure
Kidney Disease
Lupus
Migraine Headaches
Muscular Dystrophy
Multiple Sclerosis
Stroke
Thyroid Condition
Tuberculosis
Glaucoma
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Yourself
Lazy Eye
Crossed Eyes
Wandering Eyes
Double Vision
Spots or Floaters
Light Flashes
Chronic infection
Uveitis or iritis
Eye Surgery
Temporary loss of vision
Eye injury
Dry Eyes
Cataracts
Retinal Disease
Macular Degeneration
Dry Eyes
Are you pregnant?
Alcohol Abuse
Tobacco Use
Please note below any other history of significant medical or eye problems.
Yes
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Family
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Medications
List medications you are currently taking including eye
Future appts: Updates/Additions
List any changes or additions to medication previously noted on the
left.
drops:
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_______________________Date_________
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_______________________Date_________
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Signature of Patient (Guardian if patient is a minor)
________________________
Date
FUTURE APPOINTMENTS: Please note any updates to your medical or eye history
_________________________________________________________Date____________
Date____________
I have indicated updates or there are no changes in the above information:
____________________________ ______________________
Signature
Date
____________________________ ______________________
Signature
Date