Microsoft word - 1_patient_medical_information_080513

Patient Name:____________________________________________________________ Today's Date:______________ Primary Doctor: _______________________________ Referring Doctor/Clinic: _________________________________ Physicians/Specialists you want us to send correspondence of today’s visit to:___________________________________ _________________________________________________________________________________________________ Please check any medical conditions that you have or are being treated for from the list below: ____ Diabetes(age of onset____) ____ High Cholesterol ____ Multiple Sclerosis ____ Rheumatoid Arthritis ___Meningitis __________________
Females ONLY:
Are you currently pregnant? YES or NO. If yes, please give due date: ___________________ Are you currently nursing? YES or NO
Have you ever had an eye or head injury? YES or NO? If yes, specify: _________________________________________________
Have you ever had eye surgery? YES or NO? If yes, list what type of eye surgery/laser and year performed: __________
Have you had any general surgeries? (DO NOT include eye surgery) YES or NO? If yes, list______________________
FAMILY HISTORY: Please circle all of the following that apply to your immediate family (blood relatives):
UNKNOWN | NONE | Alzheimer's | Diabetes | High Blood Pressure | Cancer | Glaucoma
Macular Degeneration | Crossed Eyes | Blindness | Retinal Problems
Are you allergic to any medications? YES or NO? If yes, list the medication you are allergic to and reaction:___________
List current EYE Drops (Include ALL over the counter eye drops and eye supplements):____________________________
List all of your current medications or provide copy of your current list.(Please include over the counter meds, vitamins
and supplements): _________________________________________________________________________________
***Have you ever taken Flomax (tamsulosin), Hytrin, or any bladder intolerance medications? YES or NO? *** These
medications may cause an issue with the dilation process of the pupils, even if you are no longer taking them.
Pharmacy: _______________________________ Address:__________________________________Phone#:__________________________ Do you use tobacco products? YES or NO. If yes, what type and how often?_____________________________________________ Do you consume alcohol? YES or NO. If yes, how often?________________________________________________________________ **If you are having a specific problem today with your eyes or vision, please describe the problem on the line provided below and/or check problems from the following list: _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________ ____ Visual loss? (sudden or gradual change) ____ Burning sensation in the eyes? ____ Blurred vision at near? ____ Difficulty seeing when working with small


Microsoft word - 210907a.doc

Ufficio Polizia Municipale Consiglio di Stato - Sentenza 28 giugno 2007 n. 3782 - Sull’installazione di una insegna collocata sul tetto dell'edificio e non sull'ingresso principale dell'azienda - Non può essere considerata come una semplice insegna di esercizio, ma essenzialmente quale mezzo pubblicitario. REPUBBLICA ITALIANA IN NOME DEL POPOLO ITALIANO Il Consiglio di Stato

Ea report

Energy Ambassadors Campaign UK Concept Contents 1 Introduction ___________________________________ 1 Background to the UK Situation____________________________________________ 1 Main SWEA activities and project plan ______________________________________ 2 Timeline for main activities________________________________________________ 3 Tools and Training De

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