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Patient Medical History
Home
Patient Medical History
Today's Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Date of Birth
*
Month
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Day
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1921
1920
Pharmacy Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Referring Physician
Your Eye History
Cataract Surgery
*
Yes
No
If yes, which eye and approximate date
*
Laser Eye Surgery
*
Yes
No
If yes, which eye and approximate date
*
Other Eye Surgery
*
Yes
No
If yes, which eye and approximate date
*
Eye Disease/Injury
*
Yes
No
If yes, which eye and approximate date
*
Other Eye Problems
*
Yes
No
If yes, which eye and approximate date
*
Do you wear:
Glasses
Contacts
Cardiovascular
*
Heart Disease
High Blood Pressure
Other
None
Genitourinary
*
Kidney Disease
Renal Failure
Chronic UTI
Other
None
Immunologic
*
Shingles
Hay fever
Lupus
Sarcoidosis
HIV
Other
None
Muscular Skeletal
*
Osteoarthritis
Rheumatoid Arthritis
Carpal Tunnel
Osteoporosis
Other
None
Dermatologic
*
Skin Condition
Acne/ Rosacea
Stevens-Johnson Syndrome
Other
None
HEENT
*
Head, Ears, Eyes, Nose, and Throat
Skin Problems
Hearing Loss
Mouth Sores
Other
None
Infectious Disease
*
Hepatitis A B C
Herpes
TB
HIV
MRSA
Other
None
Neoplastic
*
Cancer
Breast Cancer
Ovarian Cancer
Colon Cancer
Lung Cancer
Brain Tumor
Prostate Cancer
Skin Cancer
Other
None
Pulmonary
*
Lung Disease
Asthma
Emphysema
Sleep Apnea
Bronchitis
COPD
Other
None
Gastrointestinal
*
Stomach Problems
Liver Disease
GERD
Gastric
Ulcer
Diverticulitis
Other
None
Hematologic
*
Bleeding Disorder
Anemia
Coumadin Therapy
Other
None
Metabolic/Endocrine
*
Non-Insulin dependent, Diabetes
Insulin dependent Diabetes
Thyroid Disease
Graves Disease
Pituitary Tumor
Other
None
Neuro/Psychiatric
*
Stroke: R L
Migraine Headaches
TIAs
Depression
Anxiety syndrome
Post-Traumatic Stress Disorder
Bells Palsy
Parkinsons
None
Women's Health
*
Pregnancy
Child Birth
Not Applicable
If others, please list:
*
General Physician
*
Physician's Phone Number
*
Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Physician's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
List any other major ILLNESSES, HOSPITALIZATIONS, and SURGERIES. (with the year if possible)
*
Date
*
*
*
*
*
*
*
*
*
Medications
Eye Medication
*
Date
*
Other Medications
*
Date
*
Are you ALLERGIC to any Medications
*
Yes
No
If YES, please list:
*
Family Medical History
Cataracts
*
Yes
No
If yes, what is their relationship to you?
*
Glaucoma
*
Yes
No
If yes, what is their relationship to you?
*
Cornea Problems
*
Yes
No
If yes, what is their relationship to you?
*
Retina Detachment
*
Yes
No
If yes, what is their relationship to you?
*
Blindness
*
Yes
No
If yes, what is their relationship to you?
*
Other
*
Yes
No
If yes, what is their relationship to you?
*
Diabetes
*
Yes
No
If yes, what is their relationship to you?
*
Heart Disease
*
Yes
No
If yes, what is their relationship to you?
*
Cancer
*
Yes
No
If yes, what is their relationship to you?
*
Do you smoke?
*
Yes
No
Do you drink?
*
Yes
No
Use/Abuse Drugs?
*
Yes
No
Comments
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