New Patient Forms Medical Office

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Medical Information
Do you have any of these problems?
High Cholesterol
Y / N
Cardiovascular
Y / N
Genitourinary
Y / N
Mental
Y / N
Gastrointesinal
Y / N
Endocrine (glands)
Y / N
Blood/Lymph
Y / N
Ears/Nose/Throat
Y / N
Integumentary (skin)
Y / N
Nervous
Y / N
Allergic/Immunologic
Y / N
Musculoskeletal
Y / N
Respiratory
Y / N
High Blood Pressure
Y / N
Seizures
Y / N
Stroke
Y / N
Explain if necessary: __________________________________________________________________________________
Please answer all that apply:
Family physician _________________________
Last Eye Exam:____________ by Dr. ___________________________
Are you diabetic? Y / N
Type ______
Date of Diagnosis __________
Headaches? Seldom ____ Occasional ____ Often ____ AM/PM ____ What part of head hurts? _______________________
Medication Allergy? _____________________________________________ What happens? ________________________
Other Allergies? _____________________________ What happens? ___________________________________________
Current medications __________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Have you had any operations? Y / N Kind? _______________________________________ When? __________________
Do you currently smoke or use tobacco products? Y / N
Have you ever smoked or used tobacco products? Y / N
Family History
Macular degeneration Y/ N Relation _________________ Cataracts Y/ N Relation ______________________________
Retinal Detachment Y/ N Relation ___________________ Diabetes
Y/ N Relation _______________________________
Glaucoma Y/ N Relation __________________________ Other Eye Conditions Y/ N Relation ______________________
Heart Disease Y/N Relation ______________________________ Cancer Y/N Relation _____________________________________
Personal Eye Information
Do you experience any of these problems with your eyes?
Burning
Y / N
Itching
Y / N
Blurred Vision
Y / N
Hurt in bright light
Y / N
Aching
Y / N
Watering
Y / N
Dry Eyes
Y / N
Double/Ghost Images
Y / N
Glaucoma
Y / N
Cataracts
Y / N
Flashes
Y / N
Floaters
Y / N
Any other problems? _________________________________________________________________________________
Past Head/Eye Trauma/Surgery? Y / N Date _______________ Do you wear:
Glasses? Y / N
Contacts? Y / N
Contact Lens Brand: _____________________ Base Curve (B.C.): _____
Prescription: Right eye ____________________________ Left eye ___________________________________________
Are you interested in wearing contact lenses? Y / N
Patient Name ___________________________________________ Date of Birth ________________ Date ____________

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