PATIENT INTAKE FORM

GENERAL INFORMATION:

OCULAR HISTORY:

Do you wear glasses
Do you wear contacts
Age- Related macular degeneration
Amblyopia (Lazy eye)
Blindness
Cataracts
Glaucoma
History of Refractive Surgery
Injury to eye region
Keratoconus
Retinopathy
Strabismus (Crossed Eyes)
Tear Film insufficiency (Dry Eyes)
OTHER:

PATIENTS PAST MEDICAL HISTORY:

Acquired Immune Deficiency Syndrome (AIDS)
Asthma
Arthritis
Cancer
COPD
Diabetes Mellitus
Emphysema
HIV
High Cholesterol
High Blood Pressure
Seasonal Allergies
Thyroid Dysfunction
Mental Disorder
Heart Disease
OTHER:

FAMILY HEALTH HISTORY (mark yes/no. If yes, specify which family member)

Amblyopia (Lazy Eye)
Blindness/ Vision Impairment
Cataract
Macular Degeneration
Glaucoma
High Blood Pressure
Stroke
Retinal Disorder
Strabismus (crossed eyes)
Arthritis
Cancer
Diabetes
Cardiovascular Disease
OTHER:

*Allen Eye Associates is now offering an additional screening test for your vision and health. This new technology can be used for early detection and successful treatment of conditions affecting your eyes. Our doctors strongly encourage you to take advantage of our Optomap Screening for $35.*


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