Do you have any allergies to medications?
Are you pregnant and/or nursing?
Do you wear contact lenses?
Please note any family history (parents, grandparents, siblings, children; living or deceased)
RELATIONSHIP TO YOU
Other, if yes please explain
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I would prefer to discuss my Social History information directly with my doctor.
If yes, do you have visual difficulty when driving?
Do you use tobacco products?
Do you use illegal drugs?
Have you ever been exposed to or infected with:
Do you currently, or have you ever had any problems in the following areas:
Chronic Infection of Eye or Lid
Flashes/ Floaters in Vision
EARS, NOSE, MOUTH, THROAT
Genitals/ Kidney/ Bladder