In order for us to better serve the needs of our new patients, we would
appreciate a brief health history to assist in the examination.

Name: _____________________________ Occupation: _______________________________
E-mail: _________________________________________________________________________
How did you hear about us : ______________________________________________________
Reason for visit (please check appropriate options):

Personal Medical History
Have you been treated for any one of the following medical conditions?
___ Diabetes (Type 1) ___ Diabetes (Type 2) ___ Hypertension (High Blood Pressure)
___ High Cholesterol ___ Thyroid
___ Atherosclerosis ___ Rheumatoid Arthritis Other: ________________________________________________________________________ Are you currently taking any medications? ___ Baby Aspirin ___ Hydro Chlorothiazide Other(s): ______________________________________________________________________ Allergies to medications? Y / N If yes, then which?_______________________________ Allergies in general? Y / N If yes, then to what? _________________________________ Do you smoke? Y / N When was your last visit to your family physician? ___ Less than 1 yr Name of family physician:_____________________________________________________
Personal Ocular History:
When was your last visit to an optometrist?
___ Less than 1 yr
Name of optometrist: _________________________________________________________ Do you use a computer on a daily basis? Y /N ___Never Have you ever worn / are you wearing contact lenses? Y / N What brand? ________________________________________________________________ Type of contact lens solution used? _____________________________________________ Any history of infections/inflammation secondary to CL wear? Y / N Have you ever had eye surgery? Y / N If yes then what type? What was the name of the eye surgeon who performed your surgery?_______________ Have you ever had an eye injury? Y / N If yes, please describe: ____________________ _____________________________________________________________________________ Have you or a family member had any of the following eye problems/disease? ____Glaucoma ____Retinal Detachment
Please specify who it is with the disease: _________________________________________
Visual Needs (please check appropriate options):
___ Work at a computer for long periods of time?
___ Have more than one pair of glasses
___ Want information on thinner, lighter lenses?
___ Wear bifocals or progressives?
___ Prefer not to wear glasses at certain times?
___ Spend a lot of time outdoors
___ Ever find a need for prescription sunglasses?
___ Have problems with glare or reflections (e.g. night driving, computer work)?
___ Do work requiring safety glasses
___ Participate in sport activities? What? __________________________________
___ Want more information about corrective vision surgery?
___ Wear or ever tried wearing contacts? What kind?________________________
___ Interested in coloured contact lenses? Full time? Part time?
All above information is for office use only and will not be used for any other purpose.



Aktieninfo Pfizer Branche: Gesundheit - Pharma 19. August 2010 Einschätzung: Wären da nicht die Patentausläufe… Halten (auf Sicht 12 Monate) Durch den Zusammenschluss von Pfizer Inc. mit Warner Lambert sowie den Kauf vonPharmacia und kürzlich der Akquisition von Wyeth wuchs die Pfizer Gruppe zum größten Arzneimittelhersteller der Welt. Der Konz


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