Medical History Name * First Name Last Name Age * DOB * MM DD YYYY Email address * Phone Number * Insurance: vision and/or medical * Reason for Exam * OCULAR MEDICAL HISTORY Date of Last Eye Exam * MM DD YYYY Name of last Eye Doctor * Do you wear glasses? * Yes No (If yes, how often?) Full Time Distance Only Near Only Previous Eye Injury/Infection/Surgery * Yes No Previous Eye Allergies? * Yes No Do you use prescription eye drops? * Yes No Do you use OTC products on the eye? * Yes No Have your previous eye doctors mentioned anything out of the ordinary about your eyes? * Yes No CONTACT LENS HISTORY Are you interested in wearing contact lenses? * Yes No Do you currently wear contact lenses? * Yes No (If yes, what type) Soft Gas Perm Scleral List Current Brand of Contact Lenses and Prescription GENERAL HEALTH HISTORY Do you have allergies to any medications? * Yes No Do you currently take prescription medicine? * Yes No CURRENT PHYSICIANS Who is your primary care physician? * Are you under the care of any specialists? * Yes No MEDICAL HISTORY Cataract? * Self Family member Self + Family member None Glaucoma? * Self Family member Self + Family member None Macular Degeneration? * Self Family member Self + Family member None Blindness? * Self Family member Self + Family member None Diabetes * Self Family member Self + Family member None SELF MEDICAL HISTORY Hypertension? * Yes No Arthritis? * Yes No Neurological Disease? * Yes No Ear/Nose/Throat Disease? * Yes No Skin Disease? * Yes No Hematological Disease? * Yes No Respiratory Disease? * Yes No Are you pregnant? * Yes No SOCIAL HISTORY Do you use tobacco? * Yes No Do you use alcohol? * Yes No Your form has been received. Thank you!
