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Eye Care History
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Indicates required field
Name
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First
Last
DOB
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Name of your eye doctor
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Date of Last Eye Exam
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Do you wear glasses:
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All the time
Occasionally
Reading
Driving
TV/ Computer
Never
EYE SURGERY: Please indicate if you had any of the following:
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Eyelid
Facelift
Botox
Cataract
Glaucoma
Retina
Other
Primary Care Physician Name
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First
Last
Date of Last Visit
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Do you were contacts:
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Yes
No
If yes, indicate Type and Hours/day:
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Please indicate if you have had any of the following:
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Floaters and spots
Glaucoma
Headaches
Itching Eyes
Lazy Eye
NIght Vision, Poor
Light Sensitive
Migraine Headaches
Seeing Halos
Seeing Flashes
Retinal Disease
Blurred Vision- Distance
Blurred Vision- Near
Bloodshot Eyes
Burning Eyes
Cataracts
Crossed Eyes
Color Vision, Poor
Dizzy Spells
Double Vision
Droopy Eyelids
General Health History
Allergies
Please indicate if you have had any of the following:
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AIDS/HIV
Arthritis
Artificial Heart Valve
Artificial Joints
Bleeding
Asthma
Diabetes
Cancer
Chemical Dependency
Emphysema
High Blood Pressure
Heart Condition
Hepatitis
Kidney Disease
Lupus
List your allergies to medicines or other substances:
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Medications
List medications you are currently taking:
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List any Eye Drops currently taking:
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