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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
METRO EYE CARE Comprehensive Patient History Name:_________________________________ Date of Birth: _________________ Review of Systems Do You Have? Yes Past Medical History □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Distortion of vision………….……. Have you ever had ? No □ Flashes…………………………... □ Abnormal sensitivity to light…….□ Halos around lights…………… □ Problems with glare……………..□ Red eye…………………………. □ Eye discomfort…………………. □ Eye dryness……………………...□ Eye itching………………………..□ Pressure in or behind the eye… □ Tearing of the eyes…………… □ Discharge……………………… □ Crusting or red eyelids………… □ Double vision…………………… □ Headaches……………………… □ Jagged lines in vision……………□ Decreased vision……………….. Date: ___________________ Yes □ Eye injury…………………………… □ Serious eye infection……………… □ Lazy eye……………………………. □ Droopy eyelid……………………….□ Corneal disease…………………… □ Cataract…………………………….. □ Retinal disorder……………………..□ Eye tumor……………………………□ Eye turning in or out………………..□ Diabetes……………………………..□ High blood pressure………………..□ Heart disease……………………….□ Lung disease………………………. □ Neurological disease……………….□ Thyroid disease……………………..□ Migraine…………………………… ..□ Lupus………… ……………………..□ Asthma…………………………… …□ Stroke……………………… ……….□ Glaucoma………………… …………□ Cancer………………..……………...□ Cholesterol……………………….….□ Eye surgery…………………………. Other illnesses:___________________________ ________________________________________ Other surgeries: ___________________________ ________________________________________ 1 No □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Comprehensive Patient History Name:_________________________________ Date of Birth: _________________ Family History Yes □ Macular Degeneration…………….□ Blindness…………………………...□ Retinal Detachment………….……□ Glaucoma…………………………..□ Do you wear contact lenses?…….□ Cataracts…………………………… No Social history □ □ □ □ □ □ Gas Perm. Disposable YES No □ Are you pregnant…………………□ Do you use a computer often…...□ Do you consume alcohol…… …..□ Other eye disorders……………...□ Do you wear glasses…………. …□ □ □ □ □ □ □ Do you smoke…………………… If so, please provide any information you may have: Soft Date: ___________________ If so, what purpose: Toric Distance Progressive (Varilux) Reading Trifocal Bifocal Half /reader Extended wear Name of Contact Lenses: Present Prescription: Base Curve (B.C.) Pharmacy Name:_________________________________ Diameter (Dia.) Pharmacy Address:_______________________________ _______________________________________________ Pharmacy Number:_______________________________ List Allergies to medications if any: Present Medication List: Are you taking Flomax? Dosage Yes Freq. No 1. ___________________________________ 1. _______________________/____________/_________ 2. ___________________________________ 2. _______________________/____________/_________ 3. ___________________________________ 3. _______________________/____________/_________ 4. ___________________________________ 4. _______________________/____________/_________ 5. ___________________________________ 5. _______________________/____________/_________ 6. ___________________________________ 6. _______________________/____________/_________ 7. ___________________________________ 7. _______________________/____________/_________ 2