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Date of Birth
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Date of last eye exam
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Medications (Rx and over-the cou
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Allergies to Medications?
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What medications are you allergi
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List Major Illnesses
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List Major Surgeries
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Eye Problems?
• • •
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Eye details
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General/Constitutional Problems?
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General/Constitutional Details
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Ears/Nose/Throat Problems
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Ears/Nose/Throat Details
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Cardiovascular Problems
• • •
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Cardiovascular Details
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Respiratory Problems
• • •
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Respiratory Details
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Gastrointestinal Problems
• • •
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Gastrointestinal Details
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Genital/Kidney/Bladder Problems
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Genital/Kidney/Bladder Details
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Females: Pregnant?
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Females: Nursing?
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Muscles/Bones/Joints Problems
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Muscles/Bones/Joints Details
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Skin Problems
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Skin Details
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Neurological Problems
• • •
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Neurological Details
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Psychiatric
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Psychiatric Details
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Endocrine Problem
• • •
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Endocrine Details
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Bloody/Lymph Problems
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Blood/Lymph Details
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Allergic/Immunologic Problems
• • •
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Allergic/Immunologic Details
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Family History of Disease
• • •
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Other Heritable Disease
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Does your vision limit any activ
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Have you had a blood transfusion
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Do you drink alcohol?
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How much alcohol per week?
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Do you smoke?
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How much per week?
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For how many years?
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New Field
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New Field
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