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2013 Patient Medical History
Date of Birth: _____________________ Emergency Contact/Phone:________________________
Family Physician: _________________________ Referring Doctor: _______________________________ Do you wear? Glasses Contact Lenses (What type?) _______________________ □ No Glasses or Contacts Ethnicity: Hispanic
Preferred Language: English / Other _____________
Race: ________________________________ Medications:
Please list below (or provide a list of) all medications & non-prescription drugs.
□ Currently taking NO medications_______________________________________________________________
Have you ever used Flomax or Avodart? Yes No Are you allergic to Latex: Yes No
List all known medical allergies
___________________________________________________________________ □ No Known Allergies
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History: Have you been diagnosed with any of the following in the past?
□ Other Eye Disease ________________________
Cataracts. Cataract Surgery? Date: Right_________ Left___________ By: _________________
Laser treatments to your eyes? Date: Right_________ Left___________ By: _________________
Retina Surgery? Date: Right_________ Left___________ By: _________________
Have you had any eye surgeries (including laser treatments)?
If so, give reason _______________________________________________________________
Patient Medical History: Have you been diagnosed with any of the following in the past?
Heart Disease/Carotid Artery Disease □ □ Autoimmune Disease (Type)____________________
□ □ Diabetes (Type I or II)_______# of years __________
□ Cancer (Type)_______________________________
Any other disease ______________ □ □ Permanent Defect from Illness or injury__________
For female patients, are you currently pregnant or nursing? Yes No
Surgical History: (Please Include Date and Type)____
Have you smoked more than 100 cigarettes in your lifetime? Yes No
Are you using or have you ever used recreational (including IV) drugs? Yes No
Family History: Has anyone in your family (blood relative) had any of the following? (Please list relationship
□ Retinal Detachment ______________________
Diabetes (IDDM/Type 2) ___________________
Diabetic Retinopathy ______________________
Corneal Disease ________________ □ □
High Blood Pressure ______________________
Heart Disease ___________________________
Retinitis Pigmentosa ____________ □ □
Other General Health Problems _______________
Date of Last Eye Exam
: __________________ Where?
Reason for today’s visit
Any medications for your eyes (prescription or over-the–counter) __________________________
(Check all that apply)
□ Blurred Vision □ Double Vision □ Contact Lens Problem □ Problems in school
□ Redness □ Dry Eye □ Burning □ Itching □ Watering □ Irritation
□ Injury □ Pain □ Light Sensitivity □ Flashes □ Floaters
(Check all that apply)
Happy with glasses? □ YES □ NO Please explain:_______________________________________________________
Happy with contacts? □ YES □ NO Please explain:_______________________________________________________
Review of Systems: Do you currently have any of the following symptoms?
□ Not currently experiencing any of the symptoms below
□ □ Heat
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Food Allergy Basics: Over 12 million Americans have food allergies; more than 3 million of them are children (that's almost 1 out of every 25 kids). The most common allergy-causing foods are peanuts, tree nuts (walnuts, pecans, almonds, cashews, etc.), milk, eggs, fish, shellfish, wheat , and soy. Recent studies showed that 3.3 million Americans are allergic