Please enable JavaScript in your browser to complete this form.Name *FirstLastBirthdayDo you have any allergies to medications? YesNoIf yes, explain... Primary Care Physician (Name and Location)Pharmacy (Name and Location)List any MEDICATIONS you are taking (Including oral contraceptives, aspirn, over the counter and home remedies...List any surgeries or surgical procedures..Check any of the following you have had:Crossed EyesLazy EyesDropping Eye LidProminent EyesGlaucomaRetinal DiseaseCataractsEye InfectionsEye InjuryAre you pregnant and/or nursing? *YesNoDo you wear glasses?YesNoDo you wear contact lenses? *YesNoFamily HistoryPlease note any immediate family history (Parents, Siblings, Children...living or deceased) All not marked will be considered no. BlindnessMotherFatherBrotherSisterDaughterSonCataracts MotherFatherBrotherSisterDaughterSonCrossed/Lazy Eyes MotherFatherBrotherSisterDaughterSonGlaucomaMotherFatherBrotherSisterDaughterSonMacular DegenerationMotherFatherBrotherSisterDaughterSonRetinal Detachment/DiseaseMotherFatherBrotherSisterDaughterSonArthritisMotherFatherBrotherSisterDaughterSonCancerMotherFatherBrotherSisterDaughterSonDiabetesMotherFatherBrotherSisterDaughterSonHeart DiseaseMotherFatherBrotherSisterDaughterSonHigh Blood PressureMotherFatherBrotherSisterDaughterSonKidney DiseaseMotherFatherBrotherSisterDaughterSonLupusMotherFatherBrotherSisterDaughterSonHyperthyroid DiseaseMotherFatherBrotherSisterDaughterSonHypothyroid Disease MotherFatherBrotherSisterDaughterSonSocial History Do you use tobacco products? NoCigarettesCigarsPipesSmokeless Tobacco OtherIf you use tobacco, how often...Former SmokerCurrent SmokerCurrently smoke every dayCurrently smoke some daysDo you drink alcohol? SociallyRarelyOccasionallyNeverAre you on a device daily? YesNoIPAD, Phone, Tablet, ComputerDo you use additive agents?YesNoHave you had COVID-19?YesNoWere you vaccinated for Covid-19?YesNoYour Medical HistoryConstitutional Developmental DisabilitiesWeightloss/gainFeverFatigue SyndromeTraumaCancerOtherNeurologicMultiple SclerosisEpilepsyCerebral PalsyTumorStoke/CVAMigrainesAutism Spectrum DisorderOtherEars, Nose, Throat, MouthHearing LossSinusitisDry MouthChronic CoughOtherPsychiatricDepressionADHDAnxiety DisorderBipolar DisorderOtherCardiovascular High Blood PressureStrokeHeart DiseaseVascular DiseaseCongestive Heart FailureRespiratory Cigarette SmokerAsthmaChronic BronchitisEmphysemaChronic ObstructionSleep ApneaOtherGastro (stomach)Crohn'sColitisUlcerAcid RefluxCeliac DiseaseOtherGenitourinary Kidney DiseaseProstate Disease/CancerSTDBenign Prostate HypertrophyHerpesChlamydiaGonorrheaSyphilisHIVHepatitisOtherMusculoskeletalArthritisOsteoarthritisFibromyalgiaMuscular DystrophyOsteoporosisGoutOtherIntegumentary EczemaRosaceaPsoriasisHerpes Simplex/Cold SoresHerpes Zoster/ShinglesOtherEndocrineDiabetes Type 1Diabetes Type 2Thyroid DysfunctionHormonal DysfunctionOtherLymphatic/HemotologicAnemiaLarge-volume blood lossLeukemiaBlood ThinnerUlcerHigh CholesterolOtherAllergic/Immunologic Rheumatoid ArthritisLupusSjogren's SyndromeOtherEyesCataractMacular Degeneration/ARMDGlaucomaDry EyesEye InfectionEye InflammationEye AllergyFloaters/Flashes of LightIritis/UveitisRetina Defects/DegenerationsRednessBurningItchingTearingDischargeStringy Mucus in or around the eyeForeign Body SensationContact Lens DiscomfortScratchy/Sandy/Gritty SensationLASIKCataract SurgeryBlurred VisionEyestrainEye PainSevere Light SensitivityHeadachePoor Night GlareDouble VisionTotal Loss of VisionOtherSubmit
