Patient Registration And Health History Form Page 2

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Have you ever been diagnosed with the following:
Cataracts:
YES
NO
When were you diagnosed? _____________________________________________________________
Glaucoma: YES
NO
When were you diagnosed? _____________________________________________________________
Macular Degeneration? YES
NO When were you diagnosed? ______________________________________________________
Do you wear contact lenses?
YES
NO
If Yes, type: _____________________________________________________
If No, Are you interested in wearing contact lenses?
YES
NO
Does your vision limit any activities of daily living (driving, reading, sports, computer, work etc,)? YES
NO
Are you concerned about UV damage to your eyes? __________________________________________________________________
Are you interested in learning more about refractive surgery (LASIK)? YES
NO
Are you concerned or worried about macular degeneration? YES NO
Cataracts? YES NO
Glaucoma? YES NO
MEDICAL HISTORY
List any MEDICATIONS you currently take (Rx and over-the-counter)__________________________________________________
____________________________________________________________________________________________________________
Do you have ALLERGIES to any medications or other allergies (i.e. outdoor, bees etc) ? YES
NO
If YES, please list: ____________________________________________________________________________________________
List all Major Illnesses: (diabetes, high blood pressure, heart attack, stroke, etc): __________________________________________
____________________________________________________________________________________________________________
Do you currently have any problems in the following areas?
YES
NO
DETAILS
General/Constitutional (fever, heat stroke, weight loss/gain)
Ears, Nose, Throat (hard of hearing, stuffy nose, ear ache, cough, dry mouth)
Cardiovascular (high BP, racing pulse etc)
Respiratory (congestion, wheezing, short of breath, emphysema etc)
Gastrointestional (stomach upset, diarrhea, constipation, ulcers, hernia etc)
Genital, kidney, bladder (frequent/painful urination, jaundice, etc)
Females Are you pregnant? Nursing? Or Taking Birth Control?
Muscles, bones, joints (joint pain, stiffness, swelling,, cramps, arthritis, etc)
Skin (pimples, warts, growths, rash etc)
Neurological (numbness, headaches, seizures, paralysis, etc)
Psychiatric (anxiety, depression, insomnia etc)
Endocrine (diabetes, hypothyroid etc)
Blood Lymph (bleeding, high cholesterol, anemia, etc)
Allergic/Immunologic (sneezing, redness, itching, hives, lupus etc)
FAMILY HISTORY
Has any member of your family had the following diseases; please specify relation
Blindness ______________ Cataract ______________ Glaucoma ______________ Macular Degeneration _________________
Diabetes _____________ Hypertension ________________ Stroke _______________ Thyroid Disease ___________________
Other heritable disease: ________________________________________________________________________________________
SOCIAL HISTORY
Do you drink alcohol? YES
NO
If YES, how much? _________________________________________________________
YES
NO If YES, how much? ________________ How many years? ________________
Do you use any tobacco products?

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