• MEDICAL HISTORY QUESTIONNAIRE

  • DOB
     - -
  • Are you allergic to any medications?
  • Allergic to

  • PAST EYE HISTORY

  • Do you currently take any eye drops?
  • Rows
  • Do you have any allergies to eye drops?
  • History of cataract, glaucoma
  • History of crossed/lazy eye
  • Eye injury or other trauma
  • Eye disease(s)
  • Eye surgery
  • Do you wear contact lenses?
  • Type
  • List major illnesses

  • Advanced Care Planning

  • Do you have a health care agent? This is a family member or a friend who is able to speak on your behalf if you are in a limited capacity or not able to make medical decisions for yourself. Please list your health care agent if you have someone designated:

  • PAST MEDICAL HISTORY

  • VACCINATION

  • FAMILY OCULAR HISTORY

  • Rows

  • SOCIAL HISTORY

  • Do you drink alcohol?
  • Smoking status
  • Do you now or have you ever used illegal drugs?

  • REVIEW OF SYSTEMS

    Do you presently have any problems in the following areas? If YES, give an explanation.
  • Rows
  • Are any of the following activities difficult for you?
  • Date
     - -
  • Should be Empty: