Welcome to Clarity Eye Care!

Please complete the following information to help us understand you and your eyes.
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Date of Exam
Legal first name
Middle initial
Last name
What should we call you?
She/her, He/they, etc.
select all that apply
select all that apply
(choose all that apply)
(approximate date is OK)
(approximate is ok)

Have YOU ever had or been diagnosed with:

Are you CURRENTLY or RECENTLY experiencing any of the following with your eyes?

(Dry, watery, itchy, tired, burning, sore, strained, or painful)

Personal Medical History: Have you ever been diagnosed with any of the following?

(For example: High Blood pressure, Heart disease, High Cholesterol, Stroke, or Vascular disease)
(For example: Cancer, Developmental Disability, Weight gain/loss, Loss of appetite, or Night sweats)
(For example: Multiple Sclerosis, Epilepsy, Seizures, Cerebral Palsy, or Frequent headaches)
(For example: Anemia, Leukemia, Clotting disorders, Dyscrasia)
(For example: Eczema, Rosacea, Acne, Psoriasis, or Atopic Dermatitis)
(For example: Diabetes, Thyroid disorder, Hormonal Dysfunction, or PCOS)
(For example: Osteoarthritis, Fibromyalgia, Muscular dystrophy, Ankylosing Spondylitis, or Gout)
(For example: Acid reflux, Crohn's disease, Inflammatory Bowel disease/syndrome)
(For example: Asthma, COPD, Emphysema, Bronchitis, Cystic Fibrosis, or Sarcoidosis)
(For example: Depression, Anxiety, ADHD/ADD, Bipolar, or Schizophrenia)
(For example: HIV/AIDS, Rheumatoid Arthritis, Lupus, Allergic disorders, Neurofibromatosis, Scleroderma, or Sjogren's syndrome)
(For example: Hearing loss, Upper respiratory infection, Sinus disorders, Tinnitus, or Meniere's disease)

Please list any and all medications that you are currently taking, INCLUDING prescription and non-prescription medications, creams, and eye drops, vitamins, and supplements, along with what you are taking them for. If you are not taking any medications, please list 'none'

if you are not using any medications or supplements, please type 'none'

Family history: Have any of your blood relatives (parents, grandparents, children, living or deceased) been diagnosed with any of the following:

Please list the name(s) of any other adult(s) you would like to have access to this patient's medical information for any reason
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