Medical History
Referred By: |
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Interested In Contact Lenses? |
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Ever Worn Contact Lenses? |
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Type of CLs worn in past: |
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Back up specs for cls? |
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Primary Vision Correction: |
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Interested in Laser Vision Correction? |
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Eye Hx: Infections, Injuries, Surgeries |
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Family Eye History: (GLC, AMD) |
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Med Hx: (Diabetes,HTN,Seizures,Thyroid,Arthritis) |
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Drug or Seasonal Allergies: |
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SYSTEM
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
General:
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic