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Please complete this new patient paperwork form.

Name *
Today's Date *
Date of Birth *
Sex *
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Address *
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routine, new glasses, contact lens evaluation, red/painful eye, diabetic exam, medical visit etc.

Medical History

Do you currently have any problems in the following areas? If YES, please provide additional information.

EYES (glaucoma, cataracts, retinal conditions, macular degeneration, corneal conditions etc.) *
ENDOCRINE (diabetes, thyroid etc.) *
EARS, NOSE, THROAT (deafness, stuffy nose, earache, cough, dry mouth etc.) *
GENERAL/CONSTITUTIONAL (fever, heat stroke, weight loss/gain etc.) *
CARDIOVASCULAR (hypertension, cholesterol, stroke, heart attack etc.) *
RESPIRATORY (asthma, wheezing, short of breath etc.) *
GASTROINTESTINAL (IBS, diarrhea, constipation, hernia, ulcers etc.) *
GENITAL, KIDNEY, BLADDER (painful/frequent urination, jaundice, etc.) *
FEMALES - Are you pregnant? Nursing? *
MUSCLES, BONES, JOINTS (joint pain, stiffness, cramps, arthritis, etc.) *
SKIN (eczema, growths, rash, warts etc.) *
NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) *
PSYCHIATRIC (anxiety, depression, insomnia) *
BLOOD/LYMPH (anemia, leukemia etc.) *
ALLERGIC/IMMUNOLOGIC (seasonal, lupus etc.) *

Family History

(mother, father, grandparent, sibling)

Has any member of your family had these diseases? *
Blindness, Cataract, Glaucoma, Retinal/Corneal diseases, Diabetes, Hypertension, Heart Disease, Stroke, Cancer, Thyroid Disease, Arthritis, Other heritable disease
Do you have allergies to any medications? *
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Date *