EFTA00283789.pdf

Jeffrey D Hixenbaugh OD 5616276456 p.1 Welcome to oar office Maine Date Street Address Date ofBinh City, State, ZIP Occupation Phone Home Work Cell Email Address Vision Plan Medicare 0 Last Eye Exam Date Previous Eye Dr. Medications Taken Drug Allergies Medical History Eyes/Vision YES NO Psychiatric YES NO Muscoloskeletal YES Crossed Eyes NO Y N Depression Y N Osteoporosis N Lazy Eye Y N Anxiety EYe Y N Arthritis N Bipolar Y N Fibromyalpia N Eye SurWV Attention Deal Y N Gout N Glaucoma Y N Cataracts Y N Cardiovasadar Integumentary Macular Degeneration Hypertension Y N Psoriasis N Floaters Heart Disease Routom Flashes of Light N Stroke Eczema Y N Systemic/Constitutional Respiratory Endocrine Fatigue Asthma Insulin Dep. Diabetes N Cancer Y N Bronchitis Y N Non-Insulin Dep. Diabees N • COPD Y N Thyroid Disease N Ear/N. me/Throat Emphysema Allergies/Hay Fever LyarphatirfHeniatelogical Sinus Problems Gastrointestinal High Cholesterol Chronic Cough Crohn's Disease Anemia Dry Mouth Colitis Ulcer Y N Al lergyanara analogical Neurological Digestive Y N Environmental Mkrgy Headaches N Y N Rheumatoid Arthritis N Migraines Genitourinary Lupus Seizures N Kidney Disease Drug Allergy Y N Multiple Sclerosis Pregnant Family History- has anyone in the patient's family (blood relative) had any of the following? Cataracts Y N Glaucoma Y N Retinal Disease Crossed Eyes Y N Y N Lazy Eye Macular Degeneration Hypertension N Y N Diabetes Heart D'grate Cancer Do you wear glasses? Y N Do you wear contact lenses? Y N Type of contact lenses O Rigid J Soft O Daily Wear O Overnight Wear How often do you replace your contact lenses? 0 Daily C 1-2 Weeks 0 Monthly °Painterly 0 Yearly EFTA00283789