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Wasatch view eye care

Medical History
Name_______________________________________________________ Gender: M F Date of Birth_____________ Age________ _ What is the reason for your visit?________________________________________________________________________________________ Are you taking: Accutane Imitrex Cordarone Prednisone Medications_________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Drug Allergies: ______________________________________________________________________________________________________ Medical History
Yes No Bleeding Disorder______________________________ Yes No Neurological Disease____________________________ Circle Yes or No
Yes No Heart Disease__________________________________ Yes No Diabetes; taking: Insulin / Medications / Diet-Exercise
Yes No Immune Disease________________________________ Yes No Digestive Disease_______________________________ Yes No Muscle/Skeletal Disease_________________________ Yes No Lung/Breathing Disease__________________________ Yes No Kidney/Bladder Disease_________________________ Yes No Cancer_______________________________________ Yes No Blood Disorder_________________________________ Yes No Mental Health Concerns_________________________ Yes No Skin Disease___________________________________ Yes No Liver Disease__________________________________ Yes No Thyroid Disease________________________________ Yes No Food / Seasonal Allergies________________________ Yes No Epilepsy______________________________________ Yes No Keloid Scars___________________________________ Yes No Other________________________________________ Yes No Currently pregnant or nursed in the last 3 months? Social History
Use of Alcohol: Never Rarely Moderate Daily
Use of Tobacco: Never Previously, but not in the past ________ year(s) Current packs/day _________
Use of drugs: : Never Rarely Moderate Daily
Eye History
Yes No Other________________________________________ Circle Yes or No
Yes No Do your eyes feel gritty or scratchy? Yes No Do your eyes frequently turn red? How often do you use artificial tears?_______________________ Contact Lens Wear
Yes No Eye Surgery_________________________________ What brand or type of contacts do you wear?__________________ Yes No Eye Injury__________________________________ How often do you replace your contacts?_____________________ What type of solution do you use?__________________________ How often do you take your lenses off?______________________ For LASIK, when did you last wear your lenses?______________ ________________________________________________________________________________________________
I hereby acknowledge the above to be true to the best of my knowledge. Signature_________________________________________________________________ Date_________________

Source: http://www.wasatchview.com/pdf/Medical_History.pdf

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The New Yorker The Truth Wears Off Is there something wrong with the scientific method? by Jonah Lehrer December 13, 2010 For the original New Yorker version of this article go to http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer On September 18, 2007, a few dozen neuroscientists, psychiatrists, and drug-company executives gathered in a hotel conference room in

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RESCOURCES FOR EMERGENCY ANIMAL CARE Supplies and Equipment The following is a list of basic supplies and equipment that may be useful – to be procured, delivered, maintained, stored, used, and replenished – for emergency animal care. Essentials ( □ ) are listed first, followed by items that are more rarely necessary (○). Specific disasters may require yet more specialized e

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