Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Type of Address *

Home

Office

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Work Phone *

(###)

###

####

Martial Status *

M

S

D

W

Spouse's Date Of Birth

MM

DD

YYYY

Primary Language *

English

Spanish

Other

Special Needs

Hearing Impaired

Translator

Wheelchair

Race *

White

African American

Asian

Other

Decline to Answer

Ethnicity *

Hispanic or Latino

Non-Hispanic or Latino

Unknown

Decline to Answer

Last PCP (Primary Care Physician) Visit

MM

DD

YYYY

Last Eye Exam

MM

DD

YYYY

Are you Pregnant? *

Yes

No

Are you Breastfeeding? *

Yes

No

Do you wear glasses? *

Yes

No

Do you wear contact lenses? *

Yes

No

Are you interested in contact lenses? *

Yes

No

Are you interested in refractive surgery? *

Yes

No

Do you preform fine or close-up work? *

Yes

No

Are you outdoors all or part of the time? *

Yes

No

Do you have trouble reading signs when driving at night? *

Yes

No

Are you bothered by: *

Overhead Lights

Computer Screens

Oncoming headlights at Night

None of the above

Are you sensitive in bright sunlight? *

Yes

No

Fever, Weight Loss/Gain *

Yes

No

Heart Disease *

Yes

No

High Blood Pressure *

Yes

No

High Cholesterol *

Yes

No

Stroke *

Yes

No

Vascular Disease *

Yes

No

Allergies *

Yes

No

Sinus Congestion *

Yes

No

Post Nasal Drip *

Yes

No

Chronic Cough *

Yes

No

Dry Mouth/Throat *

Yes

No

Asthma *

Yes

No

Chronic Bronchitis *

Yes

No

Emphysema *

Yes

No

Sleep Apnea *

Yes

No

Constipation *

Yes

No

Crohn's Disease *

Yes

No

Hepatitis A *

Yes

No

Hepatitis B *

Yes

No

Hepatitis C *

Yes

No

Ulcer/Reflux *

Yes

No

Bladder/Genital/Kidney *

Yes

No

Herpes Simplex *

Yes

No

Prostate *

Yes

No

Joint/Muscle Pain *

Yes

No

Osteoarthritis *

Yes

No

Rheumatoid Arthritis *

Yes

No

Skin Cancer *

Yes

No

Skin Disease *

Yes

No

Herpes Zoster/Shingles *

Yes

No

Headaches *

Yes

No

Migraines *

Yes

No

Multiple Sclerosis *

Yes

No

Gout *

Yes

No

Seizures *

Yes

No

Anxiety/Depression *

Yes

No

Diabetes Type 1 *

Yes

No

Diabetes Type 2 *

Yes

No

Thyroid/Other Glands *

Yes

No

Anemia *

Yes

No

Bleeding Problems *

Yes

No

Eczema *

Yes

No

Hives *

Yes

No

Lupus *

Yes

No

Organ Transplant *

Yes

No

Age-related macular degeneration *

Yes

No

Amblyopia (Lazy Eye) *

Yes

No

Blindness-One Eye *

Yes

No

Blindness-Both Eyes *

Yes

No

Cataracts *

Yes

No

Glaucoma *

Yes

No

History of refractive surgery *

Yes

No

Injury to the eye region *

Yes

No

Keratoconus *

Yes

No

Retinopathy *

Yes

No

Strabismus (Crossed Eyes) *

Yes

No

Tear film insufficiency (Dry Eye) *

Yes

No

Acquired Immune Deficiency Syndrome (AIDS) *

Yes

No

Arthritis *

Yes

No

Asthma *

Yes

No

Cancer *

Yes

No

Chronic Obstructive Lung Disease (COPD) *

Yes

No

Diabetes mellitus *

Yes

No

Emphysema *

Yes

No

Heart Disease *

Yes

No

Human Immunodeficiency Virus Infection (HIV) *

Yes

No

Hypercholesterolemia (High Cholesterol) *

Yes

No

Hypertensive Disorder (Hypertension) *

Yes

No

Seasonal Allergy *

Yes

No

Thyroid Dysfunction *

Yes

No

Mental Disorder *

Yes

No

Rheumatoid Arthritis *

Yes

No

Amblyopia (Lazy Eye) *

Yes

No

Blindness and/or Vision impairment *

Yes

No

Cataract *

Yes

No

Macular Degeneration *

Yes

No

Glaucoma *

Yes

No

Retinal Disorder *

Yes

No

Strabismus (Cross Eyes) *

Yes

No

Arthritis *

Yes

No

Cancer *

Yes

No

Diabetes Mellitus *

Yes

No

Hypertension (High Blood Pressure) *

Yes

No

Cardiovascular Disease *

Yes

No

Stroke *

Yes

No

Are you a drug user? *

Yes

No

Are you a: *

Non-Drinker

Social Drinker

Tobacco Use *

(Mark which one applies)

Heavy tobacco smoker

Light tobacco smoker

Never a smoker

Former smoker

No medications

No medication allergies