Patient Information AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming When was your last medical exam? mm/dd/yyyy Who is your primary care physician? Ocular History Please check all issues you have experienced or been diagnosed with: FlashesFloatersDouble visionHeadachesDry EyesEye InfectionsForeign Body SensationGlaucomaBlindnessMacular DegenerationTearingDistorted Vision / HalosRedness / ItchingGlare / Light SensitivityLazy EyeCrossed EyesRetinal Detachment / DiseaseNight Vision IssuesEye StrainCataractsN/A Have you ever had an eye injury? YesNo Do you currently wear glasses? YesNo Have you ever worn contacts? YesNo Family and Social History Please check all that apply DiabetesCancerMacular DegenerationCrossed EyesHeart DiseaseGlaucomaLazy EyeRetinal DetachmentThyroid DiseaseSickle SaleLupusHigh Blood PressureOther Do you use tobacco products? YesNo Do you drink alcohol? YesNo Have you ever had a blood transfusion? YesNo Are you currently pregnant or nursing? YesNo Do you have any allergies to medications?YesNo Other Medications:
