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PATIENT MED-HISTORY
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Do you currently wear:
Glasses YES NO
Contact Lenses YES NO
Low Vision Aids YES NO
Do you currently have or have you ever had any of the following:
Eye Surgeries YES
NO
Eye Injuries
Eye Infections
Amblyopia
Cataracts
Dry Eyes YES
NO
Light Sensitivity
Pain
Glaucoma
Lazy Eye
Macular Degeneration YES
NO
Eye Turn In / Out
Reading Problems
Tracking Problems
Other
Do you Have:
. YES NO
Diabetes
High Blood Pressure
. YES NO
Headaches
.
Medication - List any Medications:
Allergies - List any known Allergies:
Are you currently taking YES NO
prescription or non-prescription drugs?
Do you currently have any Allergies YES NO
known or perceived?
Do you have problems with any of these systems? - Please check all that apply
Allergic / Immunologic YES
NO
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument Skin
Kidney Problems YES
NO
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other (explain bottom of page)
Do you use - Please select all that apply
Cigarettes? YES NO
Alcohol? YES NO
Other substances? YES NO
Family Eye History - Anyone in patient's family (blood relative) had any of the following?
Cataracts YES
NO
Cornea Disease
Diabetes
Glaucoma YES
NO
Lazy Eye
Macular Degeneration
Retina Disease YES
NO
High Blood Pressure
Other Eye Disorders
Your Surgical History- List any type of surgery and dates of surgery
Occupation- If applicable, what type of work do you do?
Hobbies- List any hobbies or sports you participate in
Vision Correction Preferences, Interests- Put a check in any boxes that interests you
LASER VISION CORRECTION
Laser vision correction
LASIK with the new Wavefront technology
CONTACT LENSES
Contacts that are comfortable ALL day long
Disposable Contact Lenses
CRT (Corneal Refractive Therapy) a non-surgical alternative to LASIK
Contact Lenses to replace glasses
Contact lenses that I can sleep in, wake up, and see. (a non-surgical alternative to LASIK)
Contact lenses that require no care, to be worn for specific occasions
Contact Lenses that correct astigmatism
Contact Lenses that change eye color. (Even without prescription)
Bifocal Contact Lenses
EYEGLASSES
Extra thin and light eyeglass lenses
Anti-reflective (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers
Designer frames
Frames that weigh less than a feather
Invisible bifocal (No-Line progressives)
Lenses that auto-adjust to comfortable shades of color, based on the light (In/Out door)
Cosmetic tinted lenses - also tones down harsh indoor light for those who are light sensitive
Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc.
SUNGLASSES
UV (Ultra-Violet) light protection
Polaroid lenses -considerably reduces sun & reflective glare, & eliminates horizontal reflections
Sunglasses to wear with Contact Lenses
CHILDREN'S VISION
I need to know at what age should children have their first eye exam
I need to know at what age can children wear Contact Lenses
Protective eyeglasses for sports
I need to know the difference between Screenings & eye examinations
Other Information- Please elaborate on any information or from any "Other" box above.