Name

Email Address

Phone Number

Address

City

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Zip

Occupation

Hobbies

When was your last medical exam?

Primary Care provider

Please check all issues you have experienced or been diagnosed with: Please check all issues you have experienced or been diagnosed with: Flashes Floaters Double vision Headaches Dry Eyes Eye Infections Foreign Body Sensation Glaucoma Blindness Macular Degeneration Tearing Distorted Vision / Halos Redness / Itching Glare / Light Sensitivity "Lazy Eye" Crossed Eyes Retinal Detachment / Disease Night Vision Issues Eye Strain Cataracts N/A

Please Explain:

Have you ever had an eye injury? Have you ever had an eye injury? Yes No

Please Explain:

Do you currently wear glasses? Do you currently wear glasses? Yes No

How old are your current glasses?

When do you wear your glasses?

Have you ever worn contacts? Have you ever worn contacts? Yes No

Are you happy with your current contacts? Are you happy with your current contacts? Yes No

What is the name of the contact lenses that you wear?

Please check all that apply: Please check all that apply: Diabetes Cancer Macular Degeneration Crossed Eyes Heart Disease Glaucoma Lazy Eye Retinal Detachment Tyroid Disease Sickle Cell Lupus High Blood Pressure Other

Other Family Medical History:

Do you use tobacco products? Do you use tobacco products? Yes No

How much?

Do you drink alcohol? Do you drink alcohol? Yes No

How many drinks per day?

Have you ever had a blood transfusion? Have you ever had a blood transfusion? Yes No

Are you currently pregnant or nursing? Are you currently pregnant or nursing? Yes No

Do you any allergies to medications? Do you any allergies to medications? Yes No

Please list:

Please list any medications that you are currently taking (including oral contraceptives, aspirin, or other over-the-counter medications and eye drops):