Please fill out all information below as completely as possible. Be sure to click the "Submit Data" button at the bottom when finished to securely submit the form.

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Patient Information

Ocular History

During the Last 3 Months, what ocular symptoms have you experienced?

  • Blurry Vision

  • Double Vision

  • Flashes

  • Floaters

  • Dry/Gritty Eyes

  • Itchy Eyes

  • Watery Eyes

  • Painful/Sore Eyes

  • Tired Eyes

  • Light Sensitivity

  • Red Eyes

  • Mucous/Crusty Eyes

  • Crossed/Lazy Eye

  • Other Ocular Symptoms:

  • No ocular symptoms recently

Estimate your Average Hours Per Day on the following screens:

  • Desktop Monitor

  • Laptop Screen

  • Tablet/Phone

Have you ever been diagnosed with any of these Systemic Conditions that can affect the Eyes?

  • Diabetes

  • Hypertension

  • Cancer

  • High Cholesterol

  • Thyroid Problems

  • Lupus

  • Sarcoidosis

  • Sjogrens Syndrome

  • Rheumatoid Arthritis

  • Multiple Sclerosis

  • Notes:

  • None of these systemic conditions

Medical History

  • Pregnant
  • Nursing
  • No current health issues

  • No
  • Yes (please describe):

  • No
  • Yes (please describe):

Please check if you have ever had significant problems with the following systems:

  • Allergic/Immunologic

  • Cardiovascular

  • Constitutional

  • Ear/Nose/Mouth/Throat

  • Endocrine

  • Gastrointestinal

  • Genitourinary

  • Hematologic/Lymphatic

  • Integumentary

  • Musculoskeletal

  • Neurological

  • Psychiatric

  • Respiratory

Family History

Family Ocular History:

Please mark if your family has had any history of eye diseases or problems (and notate their relationship to you):

  • Cataracts

  • Glaucoma

  • Macular Degeneration

  • Retinitis Pigmentosa

  • Strabismus/Lazy Eye

  • Other:

  • No family history of ocular problems

  • Unknown family history

Family Medical History:

Please mark if your family has had any history of major health problems (and notate their relationship to you):

  • Diabetes

  • Hypertension

  • Heart Disease

  • Thyroid Disease

  • Cancer

  • Other:

  • No family history of major medical problems

  • Unknown family history


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