Medical History
**Please complete all entries
below, then push "submit" button on next tab to submit information to
our office **
**Current/Past Eye Conditions** (check
all that apply)
Any other eye problems, conditions? Explain in space
below.
(Night-time blurriness or halos, dry eyes, itchy eyes, computer eye strain,
lumps or bumps,
eye pain or
discomfort)
List any
Ocular History (Lasik, eye surgery, eye trauma,
lazy eye, cataract surgery)
List any
Allergies (Seasal, allergies to drugs, foods,
medications)
Surgeries/Injuries (Heart surgery, trauma to head, major
accidents, etc)
Medications and
Eye Drops (list any
medications currently taking, including eye drops)
**
Social History **
Alcohol use (Y/N)
Pregnant/Nursing? (Y/N)
Smoking
Rec Drugs (Y/N)
Drives (Y/N)
Hobbies
**Personal History** (select all that apply to you)
**
Family Medical History ** (Check if any family
members have or have had condition. Specify which family member in box
open box next to condition)