Patty Vision Center Patient Medical History Form

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Patty Vision Center Patient Medical History Form
Primary Care Physician:__________________________________________________
Patient Medical History
___ High Blood Pressure! ____ Thyroid!!
!
___ Multiple Sclerosis
___ Diabetes! !
!
____ Heart Disease!!
___ Stroke
Please List Any Other Medical Problems You Have Been Diagnosed With:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please List Any Medication You Are Currently Taking:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please List Any Eye Medication You Are Currently Taking:
______________________________________________________________________
Please List Any Medication You Are Allergic To:
______________________________________________________________________
Smoking Status (Circle The One That Best Describes You)
Non Smoker! !
!
Former Smoker
! !
!
Current Smoker
Current Everyday Smoker
Current Sometimes Smoker ! Smokeless Tobacco User
Ocular Family History (Circle if Yes)
Glaucoma !
!
Retinal Problems!
!
Blindness!
!
Other_________________________________________________________________
Ocular Surgery (Circle if Yes)
Cataract Surgery ! Glaucoma Surgery! Laser Surgery!
Strabismus Surgery
Other _______________________________________________________________

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