First Name:
*
Date of Birth: (mm/dd/yyyy)
Address:
City:
State:
Select ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DIST OF COLOMBIA FLORIDA GEORGIA IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING *
Zip:
Phone:
Emergency Contact Phone:
Primary Care Physician:
Referred By:
Email:
Hobbies, Sports, Interest:
Health History
Diabetes:
No Yes
High Blood Pressure:
Heart Disease:
Thyroid:
Seizures:
Migraines:
Arthritis:
Lupus:
Cancer:
Sinus Problems:
Neuromuscular Disease:
Immune Def, Syndrome:
Surgery (specify if applicable):
Other (explain):
Eye/Nose/Throat problems?:
Chronic fever, unexpected weight loss/gain, fatigue?:
Heart Problems:
Respiratory Problems:
Gastrointestinal Problems:
Urinary Problems:
Musculoskelital Problems:
Neurological Problems:
Psychiatric Problems:
FAMILY HISTORY
Please note any family history (parents, grandparents, siblings, children living or deceased) for the folowing conditions and list the relationship of the family member to you. If none, leave blank.
Blindness:
Cataract:
Crossed Eyes:
Glaucoma:
Macular Degeneration:
Retinal Disease:
Kidney Disease:
Thyroid Disease:
Other:
EYE HEALTH CARE QUESTIONNAIRE Visual History - Check all that apply
Eyeglasses:
Eye Surgery:
Allergies:
SPECTACLE /CONTACT LENS HISTORY
