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Patient Social and Family History

Please check all that apply Gender
Preferred Language
Race
Ethnicity
Smoking History
Family History
Check all that apply and explain if related to self or relative
Macular Degeneration
Retinal Detachment
Glaucoma
Diabetes
Ocular History
Have you had Lasik?
Do you wear Contact Lenses?
Have you worn contacts in the past?
Do you have macular degeneration?
Have you had cataract surgery?
Please list any other eye surgeries or eye disease that you have or have had:



REVIEW OF SYSTEMS
Please check each item yes or no as they relate to your health

Eyes
Pain
Double Vision
Floaters
Dry Eyes
Decreased Vision
Excessive Tears
Sandy Feeling
Musculoskeletal
Joint Pain
Stiffness
Arthritis
Ear, Nose, Throat
Hard of Hearing
Ringing in Ears
Vertigo
Gastrointestinal Problems
Stomach
Liver
Blood/Lymph
Easy Bruising
Blood Thinners
Anemia
Kidney/Urinary Problems
Prostate
Bladder
Kidney
Cardiovascular
Chest Pain
HTN
Heart Attack, if yes, when?
Pacemaker
Dizziness
Neurological
Seizures
Stroke
Alzheimer's
Psychiatric
Anxiety
Depression