List any major eye injuries, infections or surgeries and approx dates:
List any other significant eye problems you have had:
List all Rx and over-the-counter eye medications you currently use:
List any vision complaints you are currently having such as:
blurred vision, headaches, eyestrain, double vision, or losing your place when
reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or
mucus discharge
seeing rainbows around white lights at night, flashes of light or dark
spots/squiggles/webs
General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat,
sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge,
menstrual changes, impotence)
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice,
nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess
urination)
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited
movements)
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance,
dementia, speech problems)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia,
obsessive/compulsive)
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)