STEP 5--Medical History
PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below (select one per box, add your own to the last box if not listed).
Please list any Injuries, Surgeries, and/or Hospitalizations
Height
feet
inches
Weight
pounds
Are you Pregnant Or Nursing?:
Have you had a Tetanus Shot within the past 5 years?:
Did you receive this year's flu shot?:
Primary Care Physcian: Dr.
Last Visit:
Reason For Visit:
Please list any Vitamins you take:
Please list any Over-The-Counter Medications:
Please list your current Prescription Medications (including doses):
No Current Medications
Please list all drug allergies:
No Known Drug Allergies
ANSWER THIS LINE ONLY IF DIABETIC -- Last Blood Sugar Reading:
When Taken? |
Last HbA1C Reading: |
When Taken? |
ANSWER THIS LINE ONLY IF DIABETIC -- What Year Were You Diagnosed With Diabetes? |
Occupation:
Hobbies:
Smoking Status:
Type:
How Long:
Alcohol Use:
Type:
How Long:
Illegal Drug Use:
Type:
How Long:
History of STD:
Preferred Language:
Ethnicity: Race:
FAMILY MEDICAL HISTORY (Please answer each one)
Please select your closest blood relative from the drop downs below for any relevant condition (plese select None if not relevant).
Diabetes:
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Hypertension:
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High Cholesterol:
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Heart Disease:
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Thyroid Disease:
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Kidney Disease:
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Lupus:
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Arthritis:
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Asthma:
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Cancer:
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COPD:
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Back Problems:
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Headaches:
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Inflammatory Bowel Disease:
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Seizure Disorder:
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PATIENT OCULAR HISTORY
Please select if you have or had any of the following symptoms (please select yes, no, or unsure for every question):
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Are your symptoms related to the following environmental conditions? |
Windy conditions |
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,
Places with low humidity (e.g. airplanes, hospitals) |
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,
Areas that are air conditioned/heated |
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Do you use? |
Are you taking any of the following medications? |
Antihistamines / decongestants (Benadryl, Claritin, Zyrtec, Allegra, Sudafed)
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Antidepressents or anti-anxiety (Paxil, Prosac, Xanax, etc.)
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Oral corticosteroids (Prednisone, etc.)
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Hormone replacement therapy or estrogen (Premarin, etc.)
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Antihypertensives / blood pressure (e.g. diuretic, beta-blockers)
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Accutane or other oral treatment for acne
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Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? |
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,
Have you ever had punctal occlusion (punctal plugs)? |
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Have you had or are you considering Refractive Surgery (LASIK)? |
Please list your current Eye Medications
Last Eye Doctor:
Last Eye Exam:
Primary Vision Correction: Are you planning to get new glasses?
Do you have back up glasses?
Brand of Contacts currently wearing / worn in the past, Right Eye:
Base Curve (BC): Diameter: Sphere (Sph): Cylinder (Cyl): Axis: Add:
Brand of Contacts currently wearing / worn in the past, Left Eye:
Base Curve (BC): Diameter: Sphere (Sph): Cylinder (Cyl): Axis: Add:
Wear Time: Contact solution used:
How often do you sleep in contacts?:
How happy are you with your current contacts?: |
How often do you replace your CL's?:
What type of sun protection do you wear? |
When are you bothered by glare: |
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FAMILY OCULAR HISTORY (Please answer each one. Select closest relative if more than one.)
Glaucoma: |
Crossed / Lazy Eye: |
Retinal Detachment: |
Macular Degeneration: |
Cataracts: |
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS? (Please answer each one)
GENERAL: Fever, weight loss, weight gain, fatigue? |
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EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat |
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CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease |
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RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD |
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GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
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MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
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SKIN: growths, rashes, acne |
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NEUROLOGICAL: Headaches, migraines, seizures |
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PSYCHIATRIC: Depression, Anxiety, Insomnia |
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ENDOCRINE: Thyroid, Diabetes |
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BLOOD/LYMPH: Anemia, cholesterol, bleeding problems |
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ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus,
HIV |
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GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux |
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