Do you have any allergies to medications?
If yes, explain:
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
List all major injuries, surgeries, and/or hospitalizations you have had:
List any of the following that you have had:
Are you pregnant and/or nursing?
Do you wear glasses?
If yes, how old is your present pair of lenses?
Do you wear contacts?
Type of contact lenses
Are they comfortable?
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
High Blood Pressure
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Do you drive?
If yes, do you have visual difficulty when driving?
If yes, please describe
Do you use tobacco products?
If yes, type/amount/frequency
Do you drink alcohol?
Do you use illegal drugs
Have you ever been exposed to or infected with:
Do you currently, or have you ever had any problems, in the following areas:
Fever, Weight Loss/Gain
Loss of Vision
Loss of Side Vision
Foreign Body Sensation
Chronic Infection of Eye/Lid
Sties or Chalazion
Flashes/Floaters in Vision
EARS, NOSE, MOUTH, THROAT
If you answered YES to any of the above or have a condition not listed, please explain and list medications:
All EyeCare Services
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