Pindoctor: Vision Repair Service Health History
Name
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Address
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City, State, ZIP
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Phone Number
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Phone Number (cell or other)
Email Address
Emergency Contact(s) & Phone Number(s)
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Occupation (current or former)
Age
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Height
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Weight
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How did you hear about the Pindoctor?
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Please Select
Internet Search
Client
Linden Hills Booklet
Press
Word of Mouth
Other
Have you had acupuncture before?
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Yes
No
Vision History
Any primary health concerns or conditions non-vision related? (eg. diabetes, heart disease...)
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What is the primary visual problem or diagnosis for which you'd like help?
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Ophthalmologist's diagnosis, treatment plan, recommendations.
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What are your primary goals or expectations during the Vision Repair program?
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Is your vision impacting you emotionally, financially, or socially?
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Other than meds or vitamins (see below), have you tried any other therapies to help your vision?
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Vision history for your RIGHT eye. (Quality of vision, correction, injuries, surgeries, injections, etc. Please include dates if possible).
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RIGHT EYE (check all that apply)
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No Problems
Blurry Vision
Redness
Yellow Sclera ("whites of the eye")
Dry
Watery
Swelling/Drooping Eyelid
Excess Matter
Eye Muscle Control Problem
Vision history for your LEFT eye. (Quality of vision, correction, injuries, surgeries, injections,etc. Please include dates if possible).
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LEFT EYE (check all that apply)
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No Problems
Blurry Vision
Redness
Yellow Sclera ("whites of the eye")
Dry
Watery
Swelling/Drooping Eyelid
Excess Matter
Eye Muscle Control
Anything else you believe to be important about your vision or eyes?
Medications, Herbs and Supplements
Vision Specific Medications
Non-vision related Medications, include reason for each, dosage.
Over the Counter Supplements, Vitamins, Herbs, include dosage.
Head
History of headaches or migraines? If yes, what part of the head?
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Nose/Sinus
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No Problems
Allergies
Chronic Infections
Nosebleeds
Nose/Sinus (other)
Ears
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No Problems
Ringing
Hearing Loss
Excess Wax
Ears (other)
Mouth
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No Problems
Bleeding Gums/Gingivitis
Canker Sores
Tongue "ulcers"
Bad Breath
Mouth (other)
Do you floss your teeth daily?
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Yes
No
Do you have amalgam (sliver) fillings?
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Yes
No
Had them removed
Have you had a root canal?
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Yes
No
If you had a root canal, please describe which tooth/teeth. Count back from the front tooth as #1. Indicate Right or Left, Top or Bottom.
Body
How is your sleep?
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Restful
Wake Often/Restless
Wake to Urinate
Night Sweats
Hard to Fall Asleep
Apnea/CPAP Machine
Excessive Dreams
How is your mood? Do you express emotions or hold them in?
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Any Heart or Lung issues? Family history?
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Have you ever smoked cigarettes/cigars?
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Yes
No
Quit
Currently Smoke
Do you have a pacemaker or any other type of "electronic" implant?
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Yes
No
Do you have a bleeding disorder such as hemophelia?
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Yes
No
How is your digestion? Gas, cramps, acid, good appetite?
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Do you eat on a consistent schedule?
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Yes
No
What type of diet do you follow?
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"All-American"
Vegetarian/Vegan
No Red Meat
Junk Food Junkie
No Dairy
Any Food Allergies?
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Bowels
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Daily bowel movement
Tend towards constipation
Tend towards diarrhea
Hemorrhoids
Any issues with urination? Frequency, burning, control, incontinence?
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WOMEN: Menstrual history (age of menopause), pelvic surgeries, etc.
MEN: Prostate, testicular, erection issues?
Adequate Libido?
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Excellent
Good
Low
Joint/Bone/Tendon/Ligament issues? Osteoporosis?
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Any additional health concerns or illnesses, surgeries, joint replacements, etc.?
Do get at least 30 minutes of exercise per day?
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Yes
No
2-4 days/week
5-7 days/week
If "no," reasons for lack of exercise.
If "yes," types of exercise and duration.
Any specific questions for the Pindoctor?
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