Submit Your Medical History

What are your visual problems & symptoms?
How long?

Do any medical or eye diseases run in your family (e.g. diabetes, high blood pressure, cataract, glaucoma, macular degeneration)?

List any hospitalizations, operations, major illnesses & injuries:

Have you ever been treated for an eye disease or had any eye surgery or eye injury? (If yes please provide date and details)

Wear glasses*

Yes No

Use eye drops (prescription & over the counter?) List:

Yes No

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you have difficulty

Seeing road signs?Yes No

Reading?Yes No

Glare & halos?Yes No

Floating spots in VA?Yes No

Seeing at night?Yes No

In bright light?Yes No

Crossing the street?Yes No

Recognizing the faces of peopleYes No

Itchy eyes or mattering?Yes No

Chronic fever, fatigue, unexpected weight gain/loss

Yes No

If Yes, please explain

Heart problems (e.g. chest pain, irregular heart beat, high blood pressure, cholesterol)

Yes No

If Yes, please explain

Gastrointestinal problems (e.g. heartburn, abdominal pain, diarrhea, vomiting)

Yes No

If Yes, please explain

Skin problems (e.g. rashes, excessive dryness)

Yes No

If Yes, please explain

Neurological problems (e.g. numbness, weakness, headache)

Yes No

If Yes, please explain

Endocrine problems (e.g. diabetes, thyroid disease)

Yes No

If Yes, please explain

Allergies, Hayfever

Yes No

If Yes, please explain

Have you ever been exposed to Hepatitis C?

Yes No

If Yes, please explain

Please use space below if needed for further explanations.

THANK YOU, Please submit only once →

Family and Social History

Do you have difficulty

Do you currently have any of the following problems: Yes / No

First Name	Middle Initial	Last Name	Title
Address	City	State	Zip
Email	Home Phone	Cell	Age
What are your visual problems & symptoms? How long?		Do any medical or eye diseases run in your family (e.g. diabetes, high blood pressure, cataract, glaucoma, macular degeneration)?
Do you have any drug or food allergies? What are you allergic to?		If yes, list symptoms
List any hospitalizations, operations, major illnesses & injuries:		Have you ever been treated for an eye disease or had any eye surgery or eye injury? (If yes please provide date and details)
Family and Social History
Wear glasses*	Yes No	Use eye drops (prescription & over the counter?) List:	Yes No
Wear contacts*	Yes No	Do you work? If yes, how many hours per week? What kind of work do you do? List:	Yes No
Do you smoke?	Yes No	Do you drink alcohol?	Yes No
if yes, how much?	(packs)	If yes, how much?
How long?	(years)
How much do you weigh?
Do you have difficulty
Distance Vision?Yes No	Near Vision?Yes No	Driving?Yes No	With headlights?Yes No
Seeing road signs?Yes No	Reading?Yes No	Glare & halos?Yes No	Floating spots in VA?Yes No
Flashing lights in VA?Yes No	Distorted VA?Yes No	Double VA?Yes No	Headaches?Yes No
Seeing at night?Yes No	In bright light?Yes No	Crossing the street?Yes No	Recognizing the faces of peopleYes No
seeing across the street?Yes No	Redness of eyes?Yes No	Dryness of eyes?Yes No	Burning of eyes?Yes No
Itchy eyes or mattering?Yes No
Do you currently have any of the following problems: Yes / No
Chronic fever, fatigue, unexpected weight gain/loss		Yes No	If Yes, please explain
Ear/nose/throat problems (e.g. hearing loss, sinus infection, sore throat)		Yes No	If Yes, please explain
Heart problems (e.g. chest pain, irregular heart beat, high blood pressure, cholesterol)		Yes No	If Yes, please explain
Respiratory problems (e.g. shortness of breath, wheezing, coughing, asthma)		Yes No	If Yes, please explain
Gastrointestinal problems (e.g. heartburn, abdominal pain, diarrhea, vomiting)		Yes No	If Yes, please explain
Urinary problems (e.g. pain or discomfort, blood in urine)		Yes No	If Yes, please explain
Skin problems (e.g. rashes, excessive dryness)		Yes No	If Yes, please explain
Musculoskeletal problems (e.g. muscle aches, joint pain, swollen joints)		Yes No	If Yes, please explain
Neurological problems (e.g. numbness, weakness, headache)		Yes No	If Yes, please explain
Psychiatric problems (e.g. depression, anxiety)		Yes No	If Yes, please explain
Endocrine problems (e.g. diabetes, thyroid disease)		Yes No	If Yes, please explain
Blood problems (e.g. anemia, bleeding tendency)		Yes No	If Yes, please explain
Allergies, Hayfever		Yes No	If Yes, please explain
Have you ever been exposed to Hepatitis B?		Yes No	If Yes, please explain
Have you ever been exposed to Hepatitis C?		Yes No	If Yes, please explain
Have you ever tested positive for the HIV Virus?		Yes No	If Yes, please explain
Please use space below if needed for further explanations.
		THANK YOU, Please submit only once →