| NAME___________________________________ DATE_________ | |||
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1. Please circle the following EYE MEDICATIONS you are currently using: |
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| CIRCLE | CIRCLE | HOW | CIRCLE |
| MEDICATION | STRENGTH | MANY TIMES/DAY | WHICH EYE |
| Timoptic | 0.25% 0.5% | am pm twice | right left both |
| Betoptic | 0.25% 0.5% | am pm twice | right left both |
| Betagan | 0.25% 0.5% | am pm twice | right left both |
| Pilocarpine | 1% 2% 4% 10% | 1 2 3 4 | right left both |
| Trusopt or Azopt | 1 2 3 4 | right left both | |
| Ocupress or Optipranolol | 1 2 3 4 | right left both | |
| Iopidine | 1 2 3 4 | right left both | |
| Xalatan,Travatan,Lumigan | 1 2 3 4 | right left both | |
| or Rescula | |||
| Alphagan | 1 2 3 4 | right left both | |
| Diamox | 1 2 3 4 | ||
| Neptazane | 1 2 3 4 | ||
| Other _____________________________________________________________________ | |||
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| Please list general medications you are taking by mouth, along with the dosage | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ________________________________________________________________________
________________________________________________________________________ _________________________________________________________________________ |
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| Are you allergic to or sensitive to any medications? _____Yes ______ No
If so, please list them __________________________________________________________ |
| __________________________________________________________________________
__________________________________________________________________________ |
| Have you ever had a severe allergic reaction to shellfish, bee stings, nuts, etc. ___Yes ___No |
| Please list all eye surgeries you've had with their approximate dates
___________________________________________________________________________ ___________________________________________________________________________ |
| Please check any of the following conditions which apply to your health status. If unsure, indicate with a question mark ( ? ). If all normal, check here________ | ||
| Cardiac | Neurologic | |
| chest pain/angina _____ | stroke _____ | |
| irregular heart beat _____ | epilepsy, convulsions _____ | |
| congestive heart failure _____ | ||
| Endocrine | ||
| carotid artery surgery_____ | ||
| thyroid problems | ||
| angioplasty _____ | ||
| diabetes ____diet ____ oral _____insulin | ||
| bypass surgery _____ | ||
| heart murmer _____ | Musculoskeletal | |
| aortic aneurism _____ | arthritis _____ | |
| cardiac pacemaker _____ | joint replacement _____ | |
| heart valve prosthesis _____ | ||
| Lung | Infectious disease | |
| shortness of breath _____ | hepatitis _____ | |
| asthma _____ | tuberculosis _____ | |
| emphysema _____ | HIV, ARC _____ | |
| Autoimmune disease ________________ | ||
| Blood pressure | ||
| Immunodeficiency __________________ | ||
| high blood pressure _____ | ||
| low blood pressure _____ | Venereal disease _________________ | |
| Gastrointestinal | Psychiatric | |
| liver disease _____ | disorientation _____ | |
| jaundice _____ | history of depression _____ | |
| other mental illness _____ | ||
| Genitourinary | ||
| kidney dialysis _____no _____ yes | Cancer history | |
| if yes, location _________________ | ||
| _______________________________ | ||
| _______________________________ | ||
| Personal and social history | _______________________________ | |
| Do you | ||
| Live alone? _____no ______ yes | ||
| smoke cigarettes _____no _____ yes | ||
| drink alcohol _____no _____ yes | ||
| Please explain any checked items if necessary ________________________________________
___________________________________________________________________________ ___________________________________________________________________________ |
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