Dussan Eye Care
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Patient Intake Form
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Indicates required field
First Name
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Last Name
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Phone Number
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Sex
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Male
Female
Prefer not to respond
E-Mail
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Address
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City
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State
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Zip Code
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Insurance provider
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Insurance ID
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Last 4 of SS# (if applicable)
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Do you currently wear
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Glasses
Contact lenses
Neither
Pharmacy Name
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Address
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City
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State
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Zip Code
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Phone
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Do you have any visual difficulty when reading?
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Yes
No
Have you ever had eye surgery?
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Yes - Right Eye
Yes- Left Eye
No - Right Eye
No - Left eye
Do you have any visual difficulty when seeing far away?
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Yes
No
Have you ever injured your eyes? If yes, please describe
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Have you ever had or do you have any of the following eye conditions?
Currently
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Glaucoma
Macular Degeneration
Cataracts
Retinal tear
Lazy eye / eye patching
Eye Pain
Blurred/decreased vision
Plaquenil Use
Flashes of light in eye(s)
Floating dark spots eyes
Double Vision
Halos
Light Sensitivity
Redness
Itching
Burning
Dryness
Sandy/Gritty eye(s)
Foreign body sensation
Discharge
Crusting on eyelid
Drooping eyelid
Past
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Glaucoma
Macular Degeneration
Cataracts
Retinal tear
Lazy eye / eye patching
Eye Pain
Blurred/decreased vision
Plaquenil Use
Flashes of light in eye(s)
Floating dark spots eyes
Double Vision
Halos
Light Sensitivity
Redness
Itching
Burning
Dryness
Sandy/Gritty eye(s)
Foreign body sensation
Discharge
Crusting on eyelid
Drooping eyelid
Never
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Glaucoma
Macular Degeneration
Cataracts
Retinal tear
Lazy eye / eye patching
Eye Pain
Blurred/decreased vision
Plaquenil Use
Flashes of light in eye(s)
Floating dark spots eyes
Double Vision
Halos
Light Sensitivity
Redness
Itching
Burning
Dryness
Sandy/Gritty eye(s)
Foreign body sensation
Discharge
Crusting on eyelid
Drooping eyelid
Medical History
Are you currently being treated for any of the following?
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High Blood Pressure
Heart Disease
Stroke
Arthritis
None
Other
Other
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Have you ever been treated for any other serious illness or medical conditions or have had any hospitalizations or surgery? If yes, please explain:
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Do you have any drug allergies? if yes, please describe:
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Please list any medications that you take. prescription or over the counter or herbal remedies
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Chronic Fever
, sudden weigth loss/gain, fatigue
Heart
(e.g. chest pain, irregular heartbeat, hypertension)
Respiratory
(e.g. cough, wheezing, shortness of breath)
Ear/nose/throat
(e.g. hearing loss, sinus, sore throat
Gastrointestinal
(e.g. heartburn, belly pain, diarrhea)
Urinary
(e.g. pain, frequent urination, blood in urine)
Skin Problems
(e.g. dry skin, rashes, dermatitis, itching)
Musculoskeletal
(e.g. muscle aches, pain or swelling)
Endocrine
(e.g. diabetes, thyroid)
Hermatologic/Lymphatic
(e.g. leukemia, )
Psychiatric
(e.g. depression, anxiety, confusion)
Neurological
(e.g. numbness, weakness, headaches)
Are you currently experiencing problems with any of the following?
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Social History
Martial Status
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Single
Married
Separated
Divorced
Widowed
Use of Alcohol
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Never
Rarely
Socially/moderate
Daily
Use of Tobacco
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Never
Former use
Current
Use of recreational drugs
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Never
Former use
Current
Family Medical/Eye History
(e.g. diabetes, glaucoma, retinal tears/detachment, macular degeneration)
Father
Mother
Siblings
Children
Medical/Eye Disease and approx. age at diagnosis
*
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