DEMOGRAPHICS
MEDICAL HISTORY
Please check all that apply to your health condition (present or past):
SYSTEMIC MEDS (including oral birth control, aspirin, OTC meds, vitamins, home remedies) : |
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List any major injury, surgery, and/or hospitalizations (approximate year of occurence): |
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EYE HISTORY
Check any eye related conditions you currently experience or have had:
When do you throw away your contacts?
Disinfection solution:
Do you sleep in your contacts?
If you sleep in your contacts, how many days? |
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EYE MEDICATIONS (includes prescribed and OTC) |
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FAMILY HISTORY
Adopted/Family history unknown
Please note this includes siblings, parents, grandparents, and children: (living or deceased)
Blindness
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Cataracts
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Crossed eyes
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Glaucoma
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Macular degeneration
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Retinal detachment/disease
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Alzheimers/Dementia
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Rheumatoid Arthritis
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Cancer
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Diabetes
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Heart disease
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High blood pressure
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High cholesterol
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Kidney disease
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Thyroid
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SOCIAL HISTORY
Have you ever been exposed or infected with:
Gonorrhea
Chlamydia
Hepatitis
HIV
Syphillis
Tuberculosis
WORK/SOCIAL ENVIRONMENT
Please check applicable items:
BIRTHDAY, OCCUPATION, AND CELL PHONE NUMBER IS REQUIRED. PLEASE PRESS WHEN FINISHED.