Form

Pindoctor: Vision Repair Service Health History
Name *
Address *
City, State, ZIP *
Phone Number *
Phone Number (cell or other)
Email Address
Emergency Contact(s) & Phone Number(s) *
Occupation (current or former)
Age *
Height *
Weight *
How did you hear about the Pindoctor? *
Have you had acupuncture before? *

Yes No
Vision History
Any primary health concerns or conditions non-vision related? (eg. diabetes, heart disease...) *
What is the primary visual problem or diagnosis for which you'd like help? *
Ophthalmologist's diagnosis, treatment plan, recommendations. *
What are your primary goals or expectations during the Vision Repair program? *
Is your vision impacting you emotionally, financially, or socially? *
Other than meds or vitamins (see below), have you tried any other therapies to help your vision? *
Vision history for your RIGHT eye. (Quality of vision, correction, injuries, surgeries, injections, etc. Please include dates if possible). *
RIGHT EYE (check all that apply) *

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). *
LEFT EYE (check all that apply) *

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? *
Nose/Sinus *

No Problems Allergies Chronic Infections Nosebleeds
Nose/Sinus (other)
Ears *

No Problems Ringing Hearing Loss Excess Wax
Ears (other)
Mouth *

No Problems Bleeding Gums/Gingivitis Canker Sores Tongue "ulcers" Bad Breath
Mouth (other)
Do you floss your teeth daily? *

Yes No
Do you have amalgam (sliver) fillings? *

Yes No Had them removed
Have you had a root canal? *

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? *

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? *
Any Heart or Lung issues? Family history? *
Have you ever smoked cigarettes/cigars? *

Yes No Quit Currently Smoke
Do you have a pacemaker or any other type of "electronic" implant? *

Yes No
Do you have a bleeding disorder such as hemophelia? *

Yes No
How is your digestion? Gas, cramps, acid, good appetite? *
Do you eat on a consistent schedule? *

Yes No
What type of diet do you follow? *

"All-American" Vegetarian/Vegan No Red Meat Junk Food Junkie No Dairy
Any Food Allergies? *
Bowels *

Daily bowel movement Tend towards constipation Tend towards diarrhea Hemorrhoids
Any issues with urination? Frequency, burning, control, incontinence? *
WOMEN: Menstrual history (age of menopause), pelvic surgeries, etc.
MEN: Prostate, testicular, erection issues?
Adequate Libido? *

Excellent Good Low
Joint/Bone/Tendon/Ligament issues? Osteoporosis? *
Any additional health concerns or illnesses, surgeries, joint replacements, etc.?
Do get at least 30 minutes of exercise per day? *

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?
Thank you for completing this form!
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Pindoctor: Vision Repair Service Health History

Vision History

Medications, Herbs and Supplements

Head

Body

Thank you for completing this form!