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631 Saint Anne St., Suite 103
Rapid City, SD 57701
605.343.4120
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Patient Health
Please fill out the form below and click "submit".
Patient Name:
*
Date:
*
What is your main reason for coming for an eye exam?:
*
What is the date of your last exam (N/A if done at Eccarius Eye Clinic)?:
*
When did you last change your glasses, and who prescribed them (N/A if Dr. Eccarius prescribed them)?:
*
List any allergies you have:
List the medications you are currently taking:
Have you ever had any eye injuries, surgeries, or diseases?:
Ophthalmology is a specialized area of medical practice. This information is important for Dr. Eccarius to perform a thorough examination. Thank you for answering the following questions:
Do you have / have you had (please check all that apply):
A bleeding disorder
Alcoholism/alcohol abuse
Arthritis
Asthma
Bladder disorder
Blood disease
Bone disease
Bowel disorder
Breast disorder
Cancer
Chest pain
Congenital disease/defect
Depression
Diabetes mellitus
Double vision
Ear/ throat/ tonsil disorders
Eating disorder/ anorexia or bulimia
Elevated cholesterol/ triglyceride levels
Emphysema
Eye inflammation
Eye trauma
Fracture or dislocations
Gall bladder disorder
Gastrointestional disorder
Headaches (chronic/migraine)
Hearing impairment
Heart disease or murmur
Hepatitis
Herpes virus/ syphilis
High blood pressure
Kidney disorder
Liver disorder
Meningitis
Mental/ nervous/ emotional disorder
Neurological disorder
Prostate disorder
Raynaud's syndrome
Rectal disorder
Reproductive organ disorder
Seizures
Shortness of breath
Sinus disorder
Skin disorder
Sleep apnea
Spinal disorder
Stomach disorder
Stroke
Thyroid disease
Tuberculosis
Ulcers (stomach or duodenum)
Urinary tract disorder
Vein or artery disease
Do you use:
Alcohol
Tobacco
Have you ever:
had a blood transfusion
tested positive for the AIDS virus
abused intravenous drugs
taken Flomax
taken Jaylin
used corticosteroid (Prednisone)
had eye surgery
Has anyone in your family had:
Glaucoma
Crossed eyes
Retinal detachment
Macular degeneration
Please list any drug allergies you have: