Patient History Name(Required) First Last Date of Birth(Required) Month Day Year Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Employer Occupation Primary Care Physician Whom may we thank for referring you? Today's Date(Required) MM slash DD slash YYYY What is your general health? Last Physical Exam? Month Day Year Personal Medical InformationDo you have a problem with any of these systems?Gastrointestinal(Required) Yes No Diagnosis? Urinary(Required) Yes No Diagnosis? Muscle/Bones(Required) Yes No Diagnosis? Integumentary(Required) Yes No Diagnosis? Endocrine(Required) Yes No Diagnosis? Blood/Lymph(Required) Yes No Diagnosis? Allergie/Immunologic(Required) Yes No Diagnosis? Headaches(Required) Yes No Diagnosis? High Blood Pressure(Required) Yes No Diagnosis? Eyes(Required) Yes No Diagnosis? Mental(Required) Yes No Diagnosis? Ears/Nose/Throat(Required) Yes No Diagnosis? Cardiovascular(Required) Yes No Diagnosis? Respiratory(Required) Yes No Diagnosis? Other(Required) Yes No If yes, please explain(Required) Diabetes(Required) Yes No Type(Required) Date of Diagnosis(Required) Month Day Year Allergies to Medicine(Required) Yes No Which?(Required) Current Medications?Do you currently use tobacco?(Required) Yes No If so, how much? Did you previously use tobacco?(Required) Yes No Quit Date Month Day Year Do you drink alcohol?(Required) Yes No If yes, how much? Do you use drugs?(Required) Yes No If yes, how much? Family HistoryHigh Blood Pressure(Required) Yes No Relation?(Required) Diabetes(Required) Yes No Relation?(Required) Glaucoma(Required) Yes No Relation?(Required) Macular Degeneration(Required) Yes No Relation?(Required) Retinal Detachment(Required) Yes No Relation?(Required) Cataracts(Required) Yes No Relation?(Required) Personal Eye InformationDate of last eye exam? Month Day Year Dilated Yes No Do you have any eye conditions or problems?Have you had any eye operations/injuries Yes No Type: Date Month Day Year Do you have glaucoma? Yes No Retinal Detachment Yes No Cataracts Yes No Blurred Vision Yes No Contact Lenses Yes No Dry Eye Yes No Macular Degeneration Yes No Vision RequirementsHow many hours per day do you spend:Daytime Driving Night Driving Outdoors Playing Sports At a computer Other Activity I am interested in: New Frame New Lenses Computer Glasses Contact Lenses Sunglasses Refractive Surgery. CAPTCHA