Patient Information
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Australia Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Armenia Aruba Austria Azerbaijan Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island (Bouvetoya) Brazil British Indian Ocean Territory (Chagos Archipelago) British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kazakhstan Kenya Kiribati Korea Korea Kuwait Kyrgyz Republic Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Mexico Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Netherlands) Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia & S. Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Daytime Phone
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Personal Information
Gender*
Female Male
Date of Birth*
Communication Preference
Select Communication Preference > Email Postal Telephone
Eye History
Please check off any current conditions you suffer from
I stopped wearing glasses I stopped wearing contact lenses Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision
Glasses History
Do you wear glasses?
Yes No
Contact Lens History
Do you wear contact lenses?
Yes No
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you drink alcohol > No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
Do you smoke?
Do you smoke > No Yes, 1/2 a pack per day Yes, 1 pack per day Yes, more than 1 pack per day
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( e.g. Hearing loss, sinus problems, sore throat) Heart problems (e.g. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (e.g. Shortness of breath, wheezing, coughing) Gastrointestinal problems (e.g. Heartburn, abdominal pain, diarrhoea, vomiting) Genitourinary problems (e.g. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (e.g. Muscle aches, joint pain, swollen joints) Skin problems (e.g. Rashes, excessive dryness, growths or lumps) Neurological problems (e.g. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (e.g. Depression, anxiety) Endocrine problems (e.g. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (e.g. Bruising, weakness, unusual paleness, swollen glands) Immune problems (e.g. Frequent infections, allergic reactions to foods, dust, pollen)
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