Last Name

First Name

Birth Month

Date

Year

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

E-mail Address

Name of Employer

Occupation

Address

City

State

Zip

Special visual demands (work or hobbies)

When was your last eye exam?

With Whom?

Have you ever been told you have:

Allergies

Cancer

Cataracts

Diabetes

Eye infections

Glaucoma

HIV

High blood pressure

Keratoconus

Lazy Eye

Macular degeneration

List Medical Problems

Do you Smoke?

Have you ever had any injury or surgery to your eyes?

Describe

Are you experiencing any problems with your eyes?

Describe

Has any blood line relatives had glaucoma or other loss of sight?

Who?

Please list your current medications

Are you allergic to any medications?

(list)

Do you presently wear glasses?

How old are the glasses?

When do you wear them?

Do you presently wear contacts?

Gas Permeable

Soft

If Yes, how old are the contacts?

If No, have you ever worn contacts?

Are you interested in contacts lenses?

Are you interested in refractive surgery?