Medical Vision History Click here to download a printable version if you prefer not to submit your information online STEP 1: Vision History Do you now or have you ever had any of the following eye conditions? Blurred Vision: NoYes Itching: NoYes Tearing: NoYes Diabetic Retinopathy: NoYes Eyestrain: NoYes Eye Pain: NoYes Wear Glasses: NoYes Wear Contacts: NoYes Blindness: NoYes Dry Eyes: NoYes Crossed Eyes: NoYes Lazy Eye/Amblyopia: NoYes Eye Injury: NoYes Eye Operation: NoYes Flashes/Floaters: NoYes Cataracts: NoYes Glaucoma: NoYes Diabetes: NoYes Detachment: NoYes Macular Degeneration: NoYes Frequent Eye Infections: NoYes Discharge: NoYes Iritis or Uveitis: NoYes Poor Night Vision: NoYes Night Glare: NoYes Redness: NoYes Double Vision: NoYes Burning: NoYes Sensitivity to Eye Meds: NoYes Severe Sensitivity to Light: NoYes Eye Disease: NoYes Other: If you selected 'Yes' to any of the conditions, please explain Please describe any eye injuries or eye surgeries Next STEP 2: Review of Systems Do you have now or have you ever had any of the following medical conditions? Development Delays: NoYes Fatigue Syndrome: NoYes Hearing Loss: NoYes Sinusitus: NoYes Dry Mouth: NoYes Laryingitis: NoYes Multiple Sclerosis: NoYes Epilepsy: NoYes Cerebral Palsy: NoYes Tumors: NoYes Stroke: NoYes CVA: NoYes Migraines: NoYes Autism Spectrum Disorder: NoYes Depression: NoYes Attention Deficit Disorder: NoYes Anxiety Disorder: NoYes Bipolar Disorder: NoYes Hypertension: NoYes Stroke: NoYes Vascular Disease: NoYes Congestive Heart Failure: NoYes Cigarette Smoker: NoYes Bronchitis: NoYes COPD: NoYes Sleep Apnea: NoYes Crohns: NoYes Colitis: NoYes Celiac Disease: NoYes Ulcer: NoYes Acid Reflux: NoYes Prostate Disease: NoYes STD-Herpetic: NoYes Chlamydia: NoYes Benign Prostate Hypertrophy: NoYes Arthritis: NoYes Osteoarthritis: NoYes Fibromyalgia: NoYes Muscular Dystrophy: NoYes Ankylosing Spondylitis: NoYes Osteoporosis: NoYes Gout: NoYes Eczema: NoYes Rosacea: NoYes Headaches: NoYes Psoriasis: NoYes Herpes Simplex: NoYes Cold Sores: NoYes Herpes Zoster: NoYes Shingles: NoYes Type 1/2 Diabetes: NoYes Hormonal Dysfunction: NoYes Anemia: NoYes Blood Loss: NoYes Ulcer: NoYes Rheumatoid Arthritis: NoYes Lupus: NoYes Sjogrens: NoYes Skin Problems: NoYes Allergies: NoYes Asthma: NoYes Emphysema: NoYes Heart Disease: NoYes Kidney Disease: NoYes High Cholesterol: NoYes Cancer: NoYes Currently Pregnant: NoYes Currently Nursing: NoYes Other: If you selected 'Yes' to any of the conditions, please explain BackNext"] STEP 3: Medication Please list medications of any kind that you are currently taking and the dosage Please list any known allergies or sensitivities to any medication and reaction BackNext STEP 4: Family History Cancer NoneMotherFatherGrandparentDaughterSonSisterBrother Cataracts NoneMotherFatherGrandparentDaughterSonSisterBrother Glaucoma NoneMotherFatherGrandparentDaughterSonSisterBrother Other Macular Degeneration NoneMotherFatherGrandparentDaughterSonSisterBrother Crossed Eyes NoneMotherFatherGrandparentDaughterSonSisterBrother Thyroid Issues NoneMotherFatherGrandparentDaughterSonSisterBrother High Blood Pressure NoneMotherFatherGrandparentDaughterSonSisterBrother Diabetes NoneMotherFatherGrandparentDaughterSonSisterBrother BackNext STEP 5: Health Habits NOTE: This information is kept strictly confidential Do you smoke or use tobacco products? NoYes Do you drink alcohol? NoYes Do you use any kind of illegal drugs? NoYes Have you ever been infected with Gonorrhea? NoYes Have you ever been infected with Hepatitis? NoYes Have you ever been infected with HIV? NoYes Have you ever been infected with Syphilis? NoYes Please indicate hobbies and interests BackNext FINAL STEP: Signature Patient Name * Date of Birth * Guardian Name Back Δ