Ophthalmology Patient Registration Form - Nethery Eye Associates Page 2

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Have you had any eye surgeries? Yes
No
If yes, please list surgery and date:
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you use eye drops? Yes
No
If yes, please list they name of eye drops you are currently using: _____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you currently taking any medications? Yes
No
If yes, please list medications: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you allergic to any medications? Yes
No
If yes, please list medications: _________________________________________________________________
__________________________________________________________________________________________
Have you ever smoked? Yes
No
When did you quit? _______________________________________
Do you drink alcohol? Yes
No
If yes, how many drinks do you have in a typical day? _____________
If over 65, How many times in the past year have you had 4 or more drinks in a typical day? _______________
Current Occupation: _________________________________________________________________________
If retired, please list previous occupation: ________________________________________________________
What are your hobbies / interests: _____________________________________________________________
Do you have a family history of: (If yes, please list who)
Diabetes:
Yes
No
Who:___________________________
Stroke:
Yes
No
Who:___________________________
Heart Attack:
Yes
No
Who: ___________________________
Glaucoma:
Yes
No
Who:____________________________
Macular Degeneration:
Yes
No
Who: ___________________________

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