Medical History

Patient Info

Past Medical History and Review of Systems

Please mark Yes or No, provied any Yes answer in deignated area below

Yes
No

Currently Pregnant or Nursing

Auto Immune Deisease (Lupus, Sarcoid, Wegener's, Fibromyalgia, Rheumatorid)

Infectious Disease (HIV, Hepatitis)

Depression / Anxiety Disorders

Skin Disorders (specify below)

Arthritis (specify below)

Diabetes

High Blood Pressure

Heart Disease (specify below)

Strokes

Asthma or Lung Disease

Thyroid Problems

Stomach or GI problems

Cancer (specify below)

Bone or muscle problems

List surgeries and specify from above

Medicine allergies?

None

Take Medications?

None

Past Eye History and Surgery

Please mark Yes or No, provied any Yes answer in deignated area below

Yes
No

Eye Surgery/Lasers (specify below)

Cataracts

Glaucoma

Macular Degeneration

Retinal Detachments

Lazy Eye or Muscle Surgery

Eye inflammation (iritis, episcleritis)

List eye surgeries and specify others:

Eye Drops:

R / L
R / L
R / L

What type of contacts do you wear?

Soft

Hard

Don't wear them

Have you had past contact lens problems?

No

Yes

Yes, and quit wearing them

Do you have a Family History of:

Please mark Yes or No, provied any Yes answer in deignated area below

Yes
No

Glaucoma

Macular Degeneration

Diabetes

Heart Disease or Strokes

Smoke History:

Smoke Now? never    rarely    daily   

In the past? never    rarely    daily   

Alcohol intake?never    rarely    daily   

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