Tell us about your eye or vision concerns reguarding today's visit: (Blurred Vision, Dry eyes, Red eye, Glaucoma concerns, etc....)
Do you experience any of the following?
Distance Blur Glare Flashes Tearing Cataracts Eye Injury
Near Blur Burning Headache Dryness Cataract Surgery Eye Surgery
Light Sensitivity Redness Eye Strain Glaucoma Eye Disease
Gritty Double Vision Spots Itching Lazy Eye
Poor Night Vision Floaters Soreness Nausea
Last Eye Exam:
Primary Vision Correction:
Age of Glasses:
Planning to get new glasses?
Any other eye history or concerns?
Tell us about your Contact Lenses:
Type of CLs:
Cleaner: (Optifree, Boston, One Step, Renu,Generic, etc...)
Do you have back up glasses?
What are your Hobbies?
If you are a diabetic, please answer the following:
Your Current Diabetic therapy:
How would you report your Diabetic Control?
Please list your Medical conditions: (Such as: Allergies, Arthritis, Back Problems, Cancer, Diabetes, HBP, etc....
Have you had any recent Injuries, Surgeries, or Hospitalization?
Pregnant Or Nursing:
Have you had a Recent Tetanus Shot:
Who is your Primary Care Physician?
When was your Last Visit?
What was the Reason For the Visit? (Annual, Check up, etc...)
Add any additional Information for the above questions:
Review of your over all Health:
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
Eye Medications, prescribed and over the counter:
Please list all other medications:
List any allergies to medications:
Are you taking any over the counter medications? (Aspirin, Acetomenophin, Ibuprofen, etc...)
Vitamins: (A, C, E,Zinc, Xanten, Lutein, Fish oil, etc....
Family Eye History:
Family Medical History:
Do you have a family history of Diabetes, HBP, Cancer, Cardiovascular Disease, Athritis, Kidney Disease, Lupus or Thyroid?
Type in any others:
After completing all the forms, submit the data by pressing "Submit Data" below.