• Medical History Questionnaire

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  •  -
  •  -
  • Race:
  • Ethnicity:
  • Severity
  • Severity
  • Severity
  • Past Ocular History: (Please select all that apply)
  • Any history of eyeglass prism?
  • Ocular Surgeries: (Please select all that apply)

  • Current Eye Medications: (Please list)

  • All Other Medications: (Please list)

  • Other Medical History:
  • Family History:

  • Social History: (Please mark all that apply)

  • Smoking:
  • Alcohol Use
  • Drug Use

  • Review of Systems: (Please select all that apply)

  • Eyes:
  • Ear, Nose, and Throat:
  • Cardiovascular:
  • Constitutional:
  • Respiratory:
  • Gastrointestinal:
  • Genito-Urinary:
  • Psychiatric:
  • Endocrine:
  • Blood/ Lymph Nodes:
  • Musculoskeletal:
  • Skin:
  • Neurological:
  • Immunologic:
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: