MAYO FAMILY EYE CARE LLC - Exeter Eye Care | Optometrist ...



NAME_______________________________________________________________________DATE OF BIRTH_____________________MEDICAL HISTORYDO YOU WEAR GLASSES?YES NO DO YOU WEAR CONTACT LENSES? YES NOARE YOU INTERESTED IN CONTACT LENSES TODAY?YESNOWHEN AND WHERE WAS YOUR LAST EYE EXAM? ____________________________________________________________ CHIEF COMPLAINT:_______________________________________________________________________________________________ _______________________________________________________________________________________________________________________MEDICAL CONDITIONS:_________________________________________________________________________________________________________________________________________________________________________________________________________________OCULAR CONDITIONS:__________________________________________________________________________________________________________________________________________________________________________________________________________________EYE SURGERIES/INJURIES:______________________________________________________________________________________MEDICATIONS/VITAMINS (PLEASE PROVIDE LIST IF YOU HAVE ONE).______________________________________________________________________________________________________________________________________________________________________________________ALLERGIES TO MEDICATION OR ENVIRONMENTAL:_______________________________________________________WHAT IS YOUR SMOKING STATUS: NEVER FORMER CURRENTIF APPLICABLE, ARE YOU PREGNANT AND/OR BREASTFEEDING?YESNOARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS?GENERAL (fatigue, fever, weakness, weight loss)YESNOEARS (hearing loss, earache, discharge, ringing)YESNOTHROAT (soreness, swallowing, infections)YESNOSKIN (rashes, itching, dryness, mole changes, sores)YESNOCHEST (shortness of breath, cough, chest pain, wheezing)YESNOHEART (cold extremity, murmur, ankle edema, palpitations)YESNOEYES (blurry, double vision, pain, floaters, flashes)YESNONOSE (bleeding, loss of smell, sinus problem)YESNOHEAD (headaches, injuries, dizziness)YESNOMOUTH (loss of taste, swallowing, pain, infections)YESNOGASTROINTESTINAL (abdominal pain, nausea, vomiting)YESNOGENITOURINARY (incontinence, urgency, kidney stones)YES NOFAMILY HISTORYDOES ANYONE IN YOUR FAMILY HAVE THE FOLLOWING:HIGH BLOOD PRESSUREYESNO ______________________________DIABETESYESNO_______________________________MACULAR DEGENERATIONYESNO_______________________________GLAUCOMAYESNO_______________________________BLINDNESSYESNO_______________________________ ................
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