Health HX Form - mile high eyecare

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First found May 22, 2018

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Today’s Date______________
Is This Your First Visit: YES
NO
Patient Name:_____________________________ Date of Birth_____/______/_______ Age:_________ Sex: M F
Social Security Number (For Insurance):______-______-______ Email Address:______________________________
Cell Phone:________________________ Home Phone (If different from cell):__________________
If Married, Spouse Name:_______________________ If Under 18, Parents Name:____________________________
Address:_________________________________________ City:________________ State:________ Zip:__________
Employer:_____________________________________ Occupation:______________________________________
Health Insurance Provider:______________________________ Vision Insurance Plan:________________________
Reason For Todays Visit:_____________________________________________________________________________
Date of Last Eye Exam:____________________ Where:___________________Previous Eye Doctor:________________
Do You Currently Wear Glasses? YES
NO
Do You Currently Wear Contact Lenses? YES NO
List Any Hobbies/Activities____________________________________________________________________________
How Were You Referred to Our Office?__________________________________________________________________
EYE HISTORY:
Have You Ever Been Diagnosed With Any of the Following Conditions?
Cataracts
Dry Eye
Age Related Macular Degeneration (AMD)
Eye Infection, Inflammation, or Allergy
Glaucoma
Diabetes
Floaters and/or Flashes of Light
Diabetic Retinopathy
Uveitis/Iritis
Other Eye Conditions:________________________________________________________________________________
Please List Previous Eye Surgeries (Including LASIK and Cataract Surgery) and Dates of
procedure:_________________________________________________________________________________________
Are You Experiencing Any of the Following Eye Symptoms?
Blur of Distance Vision Blur of Near Vision Redness Burning Itching Pain Tearing
Discharge Flashes of Light Floaters Digital Eye Strain (eye fatigue with computer or device use)
Poor Night Vision Glare when driving at night Double Vision Headaches when reading
 Other eye or vision problems:________________________________________________________________________
Family Eye History: Do any direct family members (Mother, Father, Brother, Sister, Grandparent) have the following?
Glaucoma_____________ Macular Degeneration_______________ Diabetic Eye Disease_______________ Cataracts_________________
Please List Any Medications That You Are Currently Taking:  NO MEDS
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please List Any Known Drug Allergies: No Drug Allergies (NKDA)
Latex Allergy
Allergic to Anesthetics
__________________________________________________________________________________________________
HEALTH HISTORY:
Please check all diagnoses that apply to you
Are You Currently:
Pregnant
Nursing
General Health:
Chronic Fatigue
Chronic Pain
Developmental Disability
Cancer (type)___________________
Ear, Nose and Throat:
Hearing loss
Sinusitis
Dry Mouth
Laryngitis
Vertigo
Neurological:
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Migraine
Autism Spectrum Disorder
Psychological:
Depression
 Attention Deficit Disorder
Anxiety Disorder Bipolar Disorder
Cardiovascular:
Hypertension (high blood pressure)
Stroke/CVA
Heart Disease
Vascular Disease
Congestive Heart Failure
Respiratory:
Asthma
Bronchitis
Emphysema
COPD
Sleep Apnea
Gastrointestinal:
Chrohn’s
Colitis
Ulcers
Acid Reflux
Celiac
Genitourinary
Kidney Disease
Prostate Disease
Sexually Transmitted Infection (STD)
Frequent Urinary Tract Infection
Musculoskeletal
Osteoarthritis Arthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Integumentary:
 Eczema
Rosacea
Psoriasis
Herpes Simplex (Cold Sores)
Herpes Zoster (Shingles)
Endocrine:
 Diabetes Type 2
Diabetes Type 1
Hypothyroidism
Hyperthyroidism
Hematological/Lymph:
 Hypercholesterolemia (high cholesterol)
Anemia
Bleeding Disorder
Allergy/Immune:
 Rheumatoid Arthritis
Lupus
Sjogren’s Syndrome
HIV/AIDS
Hormone disorder
Gout
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