• • • • • • •
| BP | BS | Pulse | Resp | O2 | Temp | Reg. Care |
BP Retake 1________________Time_____________ 2________________Time_____________ 3________________Time_____________
| Vaccinations | Drug Allergies | ||
| Medical History | Last Medical/Dental Visit | Complaint: ; Pain 1-10: | |
| Medications | Blood Thinner |
Vision
| Ocular History | Vision Problem | ||
| Eyeglasses Before? | Last Eye Exam | ||
| Are you diabetic? | Ethnicity |