Medical History
Do you have any allergies to medications?
Are you pregnant and/or nursing?
Do you wear glasses?
Do you wear contact lenses?
Type of contact lenses:
Are they comfortable?

Please note any family history (parents, grandparents, siblings, children; living or deceased)

DISEASE/CONDITION
RELATIONSHIP TO YOU
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
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.
Do you drive?
If yes, do you have visual difficulty when driving?
Do you use tobacco products?
Do you drink alcohol?
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:

Constitutional

Fever, Weight Loss/Gain

INTEGUMENTARY

Skin

NEUROLOGICAL

Headaches
Migraines
Seizures

EYES

Loss of Vision
Blurred Vision
Distorted Vision/ Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/ Watering
Glare/ Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes/ Floaters in Vision
Tired Eyes

ENDOCRINE

Thyroid/ Other Glands

EARS, NOSE, MOUTH, THROAT

Allergies/ Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/ Mouth

RESPIRATORY

Asthma
Chronic Bronchitis
Emphysema

VASCULAR/ CARDIOVASCULAR

Diabetes
Heart Pain
High Blood Pressure
Vascular Disease

GASTROINTESTINAL

Diarrhea
Constipation

GENITOURINARY

Genitals/ Kidney/ Bladder

BONES/ JOINTS/ MUSCLES

Rheumatiod Arthritis
Muscle Pain
Joint Pain

LYMPHATIC/ HEMATOLOGIC

Anemia
Bleeding Problems
ALLERGIC/ IMMUNOLOGIC
PSYCHIATRIC