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Patient information

First name

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Last name

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Nickname

Pronouns

Address

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City

State

Zip Code

Cell Phone

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Other Phone

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Birthday

SSN

Occupation

Birth Sex

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Medical History:

Medications

Over the Counter Medications

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Do you have any of these medical conditions?

Diabetes

Year Diagnosed

HbA1cS

High Cholesterol

Hypertension

Thyroid Conditions

Cancer

Other

Family Medical History

Unknown Family History

Does anyone in your family have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid

Cancer

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Glaucoma

Retinal Detach

Mac Degen

Cataracts

Lazy/Crossed Eye

Blindness

Review Of Systems

General

Ear/Nose/Throat

Cardiovascular

Respiratory

Genitourinary

Musculoskeletal

Gastrointestinal

Skin

Neurological

Psychiatric

Endocrine

Blood/Lymph

Immune

Other

Social History

Hobbies

Smoking Status

Alcohol Use

Race

Ethnicity