Medical History Medical History Name First Last This field is hidden when viewing the formDate MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY When was your last eye Exam?Do you wear glasses? Yes No If you wear glasses, what do you use them for? Distance Computer Near Full-Time Part-time Do you wear contact lenses? Yes No If you wear contact lenses how many days a week? What Brand?Please list any prescription or non prescription medications you are taking Please list any prescription or non prescription eye drops you are using YOUR OCULAR HISTORY Please give details on any YES answer.History of Eye Injury. Yes No explainHistory of Eye Infection Yes No explainHistory of Eye Disease Yes No explainHistory of Eye Turn Yes No explainHistory of Eye Surgery Yes No explainHistory of Eye Surgery (Give dates if possible) MM slash DD slash YYYY Do you have a family history of Macular Degeneration? If Yes who in the family?Do you have a family history of Glaucoma? If Yes who in the family?Do you smoke? If Yes how many packs per day?Do you drink alcohol?Do you have any communicable disease?If female, are you pregnant or nursing? Yes pregnant Yes nursing Yes both No Due Date if pregnant MM slash DD slash YYYY PERSONAL MEDICAL HISTORYPlease check whether there is a history of problems in each category.Cancer Yes No Allergies (Seasonal / Year round / Medications) Yes No Cardiovascular C High Blood Pressure / Heart Disease / Circulation Problem / Stroke) Yes No Constitutional difficulties (general feeling of wellness) Yes No Diabetes (Yr Diagnosed)/ Increased Cholesterol/Gout/Low Thyroid/Hyperthyroid Yes No Gastrointestinal/Stomach Yes No Genitourinary Yes No Head (Ear/Nose/Throat Disorder/Headaches/Migraines/Sinus Problems) Yes No Blood Disease/Lymphatic Yes No Immunologic Yes No Skin Yes No Musculoskeletal/Arthritis Yes No Neurological Yes No Psychiatric/Depression Yes No Respiratory Yes No Other Yes No Δ