New Patient Health and Ocular History

Check the Box for Any Conditions that Apply:

Describe any checks above as needed (when diagnosed, explanation of problem)
If you are diagnosed with diabetes or borderline diabetes, please answer the following questions about your condition:
What type do you have?

Type 1 DiabetesType 2 DiabetesOther
When were you diagnosed?
Last HbA1c Level or Glucose Range
If applicable, are you (if not, no need to answer this question):

PregnantNursing
Do you live alone?

YesNoAssisted LivingNursing HomeOther
List major injuries or surgeries, including approximate year:
List any other medical conditions you have, including non-drug allergies:
List vitamins/supplements you take: *
List any drug allergies you have:*
List all Rx and over-the-counter medications you take, including dosage: *

Check all that apply:

New Patient Medical and Ocular History