Jeffrey D Hixenbaugh OD Name Date Street Address City, State, ZIP Phone Home Email Address Last Bye Exam Date Previous Eye Dr. Welcome to our office 5616276456 Date of Birth Occupation Cell Medications Taken SeSeSeSeeFFSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSsSSSSSSSSSSSSSSSseseee Drug Allergies Medical History Eyes/Vision Crossed Eyes Lazy Bye Eye Injury Eye Surgery Glaucoma Cataracts Maculer Degeneration Floaters Flashes of Light ‘Systemic/Constitutional F. e Do you wear glasses? Type of contact lenses ° Add do od oot AZwZAALZzzzz <tc << Z2ZA~Z Zz Zz 22zZ2B Z2ZzZzZ ent’s family (blood relative) had any of the following? Y YES NO Musculoskeletal Y N Osteoporosis Y N Arthritis Y N Fibromyalgia Y N Gout Integumentary Y N Psoriasis Y N Rosacea Y N Eczema Endocrine Y N Insulin Dep. Diabetes Y N Non-Insulin Dep. Diabetes y N Thyroid Disease Y N Lymphatic/Hemateiogical High Cholesterol Y N Anemia Y N y N Allergy/Immunological Y N Environmental Allergy Rheumatoid Arthritis Lupus Y N Drug Allergy Y N N Retinal Disease Y N Macular Degeneration Y N Heart Disease Y N Do you wear contact lenses? GSoft ODaily Wear O Overnight Wear How often do you replace your contact lenses? O Daily (1-2 Weeks 0 Monthly OQuarterly 7 Yearly oe oo nt “« <n ain Sites nt % AALZ ZZ Z2ZzZz Z2z ZZZZ ZZZ EFTA00283789