How long since your last eye exam: 1 year 2 years 3 years 4 years 5 years never years ago cannot remember	Last Medical Exam: Years
PCP Name and Phone	Is PCP? Yes No
Are you Pregnant Or Nursing? No Yes Unsure	Are you Diabetic? Yes No
Recent Influenza Shot? No
Do you wear Contact Lenses? Yes No	Type of contact lenses Rigid Soft Extended Wear Other
Do you wear glasses? Yes No	Are they comfortable? Yes No
If yes, how old is your present pair of lenses? 1 year 2 years 3 years 4 years	Are you considering LASIK? Yes No
Please list all major Injuries, Surgeries, Hospitalizations you have had: None past pregnancy car accident surgery	Regarding your eyes, do you have/had any injuries, infections, surgeries, diseases, lazy eye or other eye problems. none Itching Burning, Stinging Eye Surgery Flashes Of Light Floaters was told "might have glaucoma" Glaucoma Cataracts Cataract surgery Strabismus/no surgery Strabismus surgery "Lazy eye" (Amblyopia) Corneal ulcer Recurrent infections LASIK RK PRK Macula degeneration Diabetic Retinopathy/monitoring Diabetic retinopathy/laser trmt foreign body history Eye injury w/ vision loss Eye injury w/o vision loss Retinal problem/unknown dx keratoconus Corneal dystrophy Stye
Please list any family members with the following conditons: Blindness, Cataracts, Crossed Eyes, Glaucoma, Macular Degeneration, Retinal Detachment/Disease, Arthritis, Cancer, Diabetes, Heart Disease, High Blood Pressure, Kidney Disease, Lupus, Thyroid Disease, or any other conditions we may need to be aware of.	Do you use tobacco products? No Yes If yes, how long? Current Every Day Smoker Current Ocassional Smoker Former Smoker Unknown
Do you drink alcohol?               No Yes Occasionally Socially If yes, how long and what type?	Do you use illegal drugs?           Yes No If yes, how long and what type?
Have you ever been exposed to or infected with HIV, Hepatitis, Gonorrhea, Syphilis, Herpes? If so please list.     None HIV Herpes Hepatitis Syphilis Gonorrhea
Do you drive? Yes No     If yes, do you have visual difficulties? Yes No	Fever, weight loss/gain, fatigue? None Fever Weight Loss Weight Gain
SKIN: growths, rashes, acne, Rosacea None pimples, warts growths rash acne melanoma rosacea	NEUROLOGICAL: Headaches, migraines, seizures None numbness, paralysis headache seizures migraines head trauma
EYES: Blur, Halos, Dryness, Tearing, Flashes, Floaters None 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 Lid Sties or Chalazion Flashes/Floaters in Vision Tired Eyes	ENDORCRINE: Thyroid, Diabetes None diabetes hypothyroid hyperthoyroid Diabetes Type I Diabetes Type II
EAR, NOSE, THROAT:Allergies, Sinus, Cough, Dry Mouth / Throat None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Runny Nose Post-Nasal Drip	RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD, Apnea None Asthma Bronchitis Emphysema COPD Sleep Apnea
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease None High BP Surgery Vascular Disease High Cholestrol	GASTROINTESTINAL: Diarrhea, Constipation None Diarrhea Constipation
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination None painful urination frequent urination impotence jaundice kidney stones incontinence bladder infection	MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury None joint pain Rheumatoid Arthritis Muscle Pain
LYMPHATIC:Anemia, bleeding problems None bleeding anemia	ALLERGIC / IMMUNOLOGIC:Rheumatoid, AIDS, Allergy Shots, Lupus None sneezing swelling redness itching hives lupus Seasonal allergies
PSYCHIATRIC:Depression, Anxiety, Insomnia None anxiety depression insomnia schizophrenia Bipolar Alzheimer's	Any other relevant information.
No Known Drug Allergy	No Current Medications