BRIGHTON EYE CARE



BRIGHTON EYE CARE

Patient’s Name: __________________________________________ DOB: _____________Today’s Date: _____________ Mailing Address: ____________________________________________________________________________________ SSN: _______________________ Occupation: ____________________________________________________________ Home Phone: ______________________ Work Phone: _______________________ Cell Phone: ____________________ Text Messaging Y/N Email Address: _________________________________________________________________ Have you ever fainted? Y/N If yes, circumstances? ________________________________________________________

|Patient’s Eye History: |Patient’s Medical History: |

|Circle all that apply. |Circle all that you have been diagnosed with. |

| | |

|Serious eye injuries ______________________ |Cardiovascular: Integumentary: Blood /|

| |Lymph: |

|Eye surgeries___________________________ |High Cholesterol Eczema |

| |Bleeding disorder |

|Red eyes / infections |Heart Attack Melanoma |

| |History of blood loss |

|Iritis |High / low blood pressure Rosacea |

| |Reynaud’s |

|Crossed / lazy eye / patching therapy |Anemia |

|_______________________________________ |Respiratory: Gastrointestinal: |

| | |

|First Glasses Age: _____ |Asthma Crohn’s Disease |

| |Allergic / Immunologic: |

|First Contact Lenses Age: ______ |Sleep apnea Ulcers |

| |Seasonal allergies |

| |COPD |

|Will you be needing new: |Lupus |

| | |

| |Psychiatric: Ear, Nose, & Throat: |

|Glasses Sunglasses Contacts |Endocrine: |

| |Depression Hearing Loss |

| |Diabetes |

| |Anxiety Dry Mouth |

| |Thyroid disorder |

| | |

| |Neurological: Musculoskeletal: |

| |Other: |

| |Stroke Arthritis |

| |Cancer |

| |Parkinson’s Fibromyalgia |

| | |

| |Multiple Sclerosis Rheumatoid Arthritis |

| |Migraine |

| | |

| |Bell’s Palsy Surgeries: |

| | |

|Patient’s Social History: | |

|Tobacco Use: |Alcohol Use: |

|Never / Quit smoking _________ ago / Currently _____pack(s) a day |Never / Socially / 1-2 drinks/day / Above average / Alcohol dependent |

| | |

|Marital Status: | |

|Single / Married / Partnered / Divorced / Widowed |Do you drive? Yes / No |

Current Medications: _______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

|Family Eye History: Parents, grandparents, siblings, child |Family Medical History: Parents, grandparents, siblings, child |

|Circle all that apply |Circle all that apply |

|□ Unknown |□ Unknown |

|□ Adopted |□ Adopted |

| | |

|Macular Degeneration Eye Turn / Lazy Eye |Cancer |

|Cataracts (younger than age 45) Blindness |Migraines |

|Retinal Detachment Glaucoma |Heart Attack Diabetes |

| |Stroke Thyroid|

|Other: ____________________________________________________ |Disorder |

|NONE |High Blood Pressure |

| |Other: ____________________________________________________ |

| |NONE |

Patient Signature: ______________________________________________________ Date: _________________

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