WHAT IS THE REASON FOR YOUR VISIT TODAY? ______
Do you wear: □ Glasses
□ Contacts
How do you think you see far away with your current prescription? □ Clear □ Blurry
How do you think you see up close with your current prescription? □ Clear □ Blurry
Do you have eyestrain or tired eyes……………………………………………………… ………. □yes
Do you have headaches from your eyes………………………………………………………….. □yes
Do you ever see double vision…………………………..…………………………………………. □yes
Have you been told you have “lazy eye”……...... …………………………………………. □yes
Have you ever had an eye infection……………………………………………………….……… □yes
Have you ever had an eye injury…………………………………………………………….…… □yes
Type of eye injury ……………………………………………………………………………………….
Have you ever had any eye surgery………………………………………………………………. □yes
Type of surgery ………………………………………………… Age @ time of surgery…………..
Do you have any history of cataracts in your family……………………………..……………... □yes
Do you have any history of glaucoma in your family …………………………………………… □yes
Do you have any history of blindness in your family……………………………………………. □yes
Do you have macular degeneration in your family……………………………………………… □yes
Is your color vision normal……………………………………………….……………….………. □yes
PLEASE CHECK ALL THAT APPLY TO YOU
□ Burning Eyes
□ Cross-Eyed/Wall Eyed
□ Discharge from Eyes
□ Dizzy Spells
□ Dryness
□ Eye Infections
□ Floaters
□ Itching Eyes
□ Lumps/Bumps
□ Red Eyes
□ Seeing Flashes
□ Twitching Eyelid
□ Watering Eyes
□ Other ______
HEALTH HISTORY
(Circle YES if you or your family, have had any history of the following)
Condition Yourself Family Condition Yourself Family
Arthritis Yes Yes High Blood Pressure Yes Yes
Asthma Yes Yes High Cholesterol Yes Yes
Cancer Yes Yes Kidney Disease Yes Yes
Type______Migraine Headaches Yes Yes
Cardiac Conditions Yes Yes Multiple Sclerosis Yes Yes
Diabetes Yes Yes Rheumatic Fever Yes Yes
Drug Sensitivity Yes Yes Shingles Yes Yes
Emphysema Yes Yes Skin Conditions Yes Yes
Epilepsy Yes Yes Stroke Yes Yes
Hepatitis Yes Yes Thyroid Yes Yes
Type______Tuberculosis Yes Yes
Herpes Simplex Yes Yes
List medications you are currently taking, including eye drops. List your allergies to medications or other substances.
MEDICATIONS ALLERGIES VITAMINS SUPPLEMENTS
______
______
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