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Youth Vision Check-Ups and Testing Adult Check-Ups and Prevention Senior Options

Thank You for Choosing Seeholzer.

Please fill out the following to begin the appointment-making process:

Information

















Medical History

Do you have any allergies to Medications?






Check any of the following that you have had:








Are you pregnant and/or nursing?

Do you wear glasses?

Do you wear contact lenses?

Check type of contact lenses:

Are your contact lenses comfortable?

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
Disease/Condition
No
Yes
Unknown
Relationship To You
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid
Other

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you drive?

If yes, do you have visual difficulty when driving?


Do you use tobacco products?


Do you use illegal drugs?

Have you ever been exposed to or infected with:

Review of Systems

Do you currently, or have you ever had any problems in the following areas:
System
No
Yes
Unknown
Constitutional
Fever, Weight Loss / Gain
Integumentary (skin)
Neurological
Headaches
Migraines
Seizures
Eyes
Loss of Vision
Blurred Vision
Distorted Vision / Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing / Watering
Glare / Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes / Floaters in Vision
Tired Eyes
Endocrine
Thyroid / Other Glands
Ears, Nose, Mouth, Throat
Allergies / Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular / Cardiovascular
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Gastrointestina
Diarrhea
Constipation
Genitourinary
Genitals / Kidney / Bladder
Bones / Joints / Muscles
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Lymphatic / Hematologic
Anemia
Bleeding Problems
Allergic / Immunologic
Psychiatric

If you answered 'Yes' to any of the above or have a condition not listed, please explain and list any medications: