Jeffrey D Hixenbaugh OD

Jeffrey D Hixenbaugh OD Welcome to oar office 5616276456 p.1 Maine Date Street Address Date ofBinh City, State, ZIP Occupation Phone Home Work Cell Email Address Last Eye Exam Date Medications Taken Vision Plan Medicare 0 Previous Eye Dr. Drug Allergies Medical History Eyes/Vision Crossed Eyes Lazy Eye EYe Eye SurWV Glaucoma Cataracts Macular Degeneration Floaters Flashes of Light Systemic/Constitutional Fatigue Cancer Ear/N. me/Throat Allergies/Hay Fever Sinus Problems Chronic Cough Dry Mouth Neurological Headaches Migraines Seizures Multiple Sclerosis YES NO Y N Y N Y N Y N Y N Y N Y N Psychiatric Depression Anxiety Bipolar Attention Deal Cardiovasadar Hypertension Heart Disease Stroke Respiratory Asthma Bronchitis COPD Emphysema Gastrointestinal Crohn's Disease Colitis Ulcer Digestive Genitourinary Kidney Disease Pregnant YES NO Y N Y N Y N Y N Y N Y N Y N Y N Muscoloskeletal Osteoporosis Arthritis Fibromyalpia Gout Integumentary Psoriasis Routom Eczema Endocrine Insulin Dep. Diabetes Non-Insulin Dep. Diabees Thyroid Disease LyarphatirfHeniatelogical High Cholesterol Anemia Al lergyanara analogical Environmental Mkrgy Rheumatoid Arthritis Lupus Drug Allergy Family History- has anyone in the patient's family (blood relative) had any of the following? Cataracts Y N Glaucoma Y N Retinal Disease Crossed Eyes Y N Lazy Eye Hypertension Y N Diabetes Cancer Macular Degeneration Heart D'grate YES Y Y Y Do you wear glasses? Y N Do you wear contact lenses? Y N Type of contact lenses O Rigid J Soft O Daily Wear O Overnight Wear How often do you replace your contact lenses? 0 Daily C 1-2 Weeks 0 Monthly °Painterly 0 Yearly NO N N N N N N N N N • N N N N N N N EFTA00283789