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0364490EYE HEALTH HISTORY 00EYE HEALTH HISTORY EYE CARE HISTORY Patient Name: _______________________________________ Please indicate if you have had any of the following: 514350081915? Floaters and spots? Glaucoma? Headaches? Itching Eyes? Lazy Eye? Light Sensitive? Migraine Headaches? Night Vision, Poor? Retinal Disease? Seeing Halos? Seeing Flashes? Temporary Loss of Vision ? Twitching Eyelid? Watering Eyes00? Floaters and spots? Glaucoma? Headaches? Itching Eyes? Lazy Eye? Light Sensitive? Migraine Headaches? Night Vision, Poor? Retinal Disease? Seeing Halos? Seeing Flashes? Temporary Loss of Vision ? Twitching Eyelid? Watering Eyes342900081915? Bloodshot Eyes? Blurred Vision – Distance? Blurred Vision – Near ? Burning Eyes? Cataracts? Color Vision, Poor? Crossed Eyes? Dizzy Spells? Double Vision? Droopy Eyelids ? Dry Eyes? Eye Infection Eye Injury? Eye Strain? Fainting spells, Blackouts00? Bloodshot Eyes? Blurred Vision – Distance? Blurred Vision – Near ? Burning Eyes? Cataracts? Color Vision, Poor? Crossed Eyes? Dizzy Spells? Double Vision? Droopy Eyelids ? Dry Eyes? Eye Infection Eye Injury? Eye Strain? Fainting spells, BlackoutsDOB: ______________________________________________Date of Last Eye Exam: ________________________________Name of your eye doctor: ______________________________Do you wear glasses: ? All the time ? Occasionally ? Reading ? Driving ? TVDo you wear contacts: ? Yes ? No Type: ________ Hours/Day: _________EYE SURGERYPlease indicate if you have had any of the following: ? Eyelid ? Cataract ? Other ___________? Facelift ? Glaucoma? Botox ? Retina041910HEALTH HISTORY 00HEALTH HISTORY Physician Name: ___________________________________________________ Date of Last Visit: ________________________0184150? AIDS/HIV? Arthritis? Artificial Heart Valve? Artificial Joints? Asthma? Bleeding? Cancer? Chemical Dependency? Diabetes ? Emphysema? Epilepsy? Eczema? Hay Fever0? AIDS/HIV? Arthritis? Artificial Heart Valve? Artificial Joints? Asthma? Bleeding? Cancer? Chemical Dependency? Diabetes ? Emphysema? Epilepsy? Eczema? Hay Fever3429000184150? Heart Condition? Hepatitis? High Blood Pressure? Kidney Disease? Lupus? Pacemaker? Skin Cancer? Skin Condition? Stroke? Thyroid Conditions? TuberculosisAre you pregnant? _________Tobacco use: _________? Heart Condition? Hepatitis? High Blood Pressure? Kidney Disease? Lupus? Pacemaker? Skin Cancer? Skin Condition? Stroke? Thyroid Conditions? TuberculosisAre you pregnant? _________Tobacco use: _________Please indicate if you have had any of the following:MEDICTIONSALLERGIES List medications you are currently taking:List your allergies to medicines or other substances:Medications:Eye Drops: ................
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