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Patient ID (TKS Staff Only)
Eye History
(Patching as a child/Accidents/Hospital Visit. Have you previously tried contact lenses, what have you tried/when) Lipiflow /IPL
Medications
(List all, prescribed and over the counter e.g Contraceptive Pill or Anti-histamines)
Allergies to Medicines
Eye Prescriptions
(Any current eye drops being used or tablets being taken to help eye conditions)
Eye Family History
Parents/Siblings/Children - any conditions such as Glaucoma, Macula Degeneration, Blindness, Myopia (short sighted), Strabismus (‘squint/caste’) Keratoconus
Eye Operations
(Such as cataract surgery, laser surgery, retinal or lid surgery)
Social History
Do you smoke or drink? - How much/Often? Hobbies? Sports?
Medical History
Do you or a close family member suffer from general (systemic) health conditions such as blood pressure, cholesterol, thyroid. For kids, were they Full Term and healthy baby (no long spell in hospital)
Contact Lens History
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