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MEDICAL HISTORY FORM

BECKER EYE CARE
  • Date Format: MM slash DD slash YYYY
  • Do you currently have, or have had any problems in the following areas?

  • Social History:

  • Family History:

  • YesNo
    Cataracts
    Glaucoma
    Diabetes
    Retinal Detachment
    Macular Degeneration
    High Blood Pressure
    Other
  • ConditionRelationship 
  • Doctor/Pharmacy:

  • NamePhone number 
  • (Not living with you )
  • Current Medication NameStrengthOral, Inject, Eyes, EtcDose (How many x a day)Reason for taking medication 
  • DrugReaction 
  • TypeDateDoctor