Patient History Form

Eye History

Currenty Wear Contacts?*

Currenty Wear Glasses?*

Please check if you or a family member have been treated for any of the following*

Cataracts

Crossed Eye

Glaucoma

LASIK or RK

Lazy Eye

Macular Degeneration

Retinal Retachment

Are you currently experiencing, or have you experienced, any of the following? Check all that apply*

Medical History

Please check if you or a family member have been treated for any of the following*

AIDS/HIV

Allergies

Arthritis

Asthma

Blood/Lymph Disorder

Cancer

Diabetes Type 1

Diabetes Type 2

Ears, Nose, Throat Conditions

Gastrointestinal Conditions

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Lupus

Neurological Conditions

Psychiatric Disorder

Seizures

Skin Conditions

Stroke

Thyroid Dysfunction (High or Low)

Are you Pregnant or Nursing?

Do You Smoke?

Have You Ever Smoke?

Do You Consume Alcohol?

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