Online Patient Forms
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Employed
Fulltime Student
Parttime Student
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Not Primary On Account: Not Primary
Have you ever worn soft contacts? Yes No
Have you ever worn hard contacts? Yes No
Eye Injuries (Foreign objects, Black eye, etc.) Yes No
Eye Disease (Cataract, Glaucoma, Macular Degeneration, Pterygium, etc.) Yes No
Eye Surgery (Cataract, Vision correction, etc.) Yes No
Disease/Condition
Yes
No
Relationship to You
Blindness
Crossed Eyes
Cataract
Glaucoma
Macular Degeneration
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease
Eyes (Ocular symptoms)
Eye Pain or Soreness
Fatigue/Tired Eyes
Dryness/ Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
Eyes (Visual Symptoms)
Squinting
Glare
Light Sensitivity
Halos
Double Vision
Loss of Vision
Blurred Vision
Flashes
Floaters
Night Vision Problems
Constitutional
Weight Loss
Weight Gain
Integumentary (Skin)
Rosacea
Metal Allergies
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Hearing Loss
Respiratory
Asthma
Emphysema
Vascular/Cardivascular
Heart Problems/Disease
Congestive Heart Failure
High Cholesterol
Gastrointestinal
Irritable Bowel Syndrome
Crohn's Disease
Endocrine
Thyroid/Other Glands
Lymphatic/Hematologic
Anemia
Bleeding
Autoimmune
Rheumatoid Arthritis
Lupus
Neurological
Headaches
Migraines
Seizures
Alzheimer's
Parkinsons's
Psychiatric
Mentally Challenged
Autism
ADD/ADHD
Dementia
Dyslexia/Reading Problems
Other: