Refractive History

Refractive Medical History

Patient Info

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)

History of Cold Sores or Herpes

Depression / Anxiety Disorders

Skin Disorders (specify below)

Adult Acne (acne rosacea)

Arthritis (specify below)

Diabetes

Thyroid Problems

Keloids or Excessive Scarring

Allergies or Severe Hayfever

Have you taken any of these medicines: Accutane, Imitrex, Cordarone

List any other major medical problems

Medicine allergies?

None

Take Medications?

None

Eye History

What do you use most of the time for distance vision?

Contacts

Glasses

Nothing

When was the last time you had contacts in?

Types of contacts?

soft

gas-perms

none

Have you quit wearing contacts because of problems wearing them?

Yes

No

If you are 40 or over, what do you currently do for reading (you may select more than one):

nothing special

bifocals

reading glasses

monovision contacts

take glasses off

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

Yes
No

Very dry eyes

Poor night vision

Prescription keeps changing a lot

Lazy eye or muscle surgery

Eyelash infections or styes

Family history of eye problems

Prior eye surgery

Eye inflammation (iritis, episcleritis)

Any other eye diseases / infections

List details for any yes answers:

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