Today's Date MM slash DD slash YYYY First Name* Last Name* Your Email* Your Date of Birth* Month Day Year When was your last eye exam? Are you using any eye medications today? Yes No Please list themDo you currently have prescription eyeglasses? Yes No Do you currently wear contact lenses? Yes No I am interested in contact lenses Have you ever had an eye injury? Yes No Briefly describe Family HistoryHave you or anyone in your family (grandparents, parents, siblings, children) been diagnosed with any of the following? Please select the appropriate response. Cataracts Self Family Member Not Applicable Please listGlaucoma Self Family Member Not Applicable Please listMacular Degeneration Self Family Member Not Applicable Please listDry Eyes Self Family Member Not Applicable Please listRetinal Detachment Self Family Member Not Applicable Please listLazy Eye or Amblyopia Self Family Member Not Applicable Please listEye Turn or Strabismus Self Family Member Not Applicable Please listLoss of Vision Self Family Member Not Applicable Please listAny other eye problems? Do you have any medication allergies? Yes No Please listDo you have any environmental allergies, such as pollen? Yes No Please listPlease list any medication that you are taking or ask our staff to make a copy of your medication list. (Including vitamins, herbs, supplements and over the counters)Tobacco use Current Past Never For Women: Are you currently pregnant or nursing? Yes No Personal Medical HistoryPlease select if any of the following applies to you. Please write in any condition(s) not listed. If you have none of these conditions, please check none. Cardiovascular High Blood Pressure High Cholesterol Heart Disease Endocrine Diabetes Thyroid Problem Hormone Dysfunction Pituitary Disorder Respiratory Asthma COPD Emphysema Psychiatric ADHD Depression Anxiety Bipoloar Schizophrenia Neurological Multiple Sclerosis Seizures Headaches Disorder Musculosketletal Arthritis Fibromyalgia Anklosing Spondylitis Immunological Lupus Shingles AIDS or HIV Constitutional Cancer Developmental Disability Hematological Anemia Leukemia Gastrointestinal Crohn's Celiac's Colitis Acid Reflux Ear/Nose/Throat Hearing Loss Sinus Infection Vertigo Meniere's Dermatologic Eczema Rosacea Psoriasis Skin Cancer Other Family Medical HistoryHas anyone in your immediate family been diagnosed with:High Blood Pressure and/or High Cholesterol Yes No Who? Heart or Vascular Disease Yes No Who? Diabetes Yes No Who? Thyroid Problem Yes No Who? Multiple Sclerosis Yes No Who? Migraines/Headaches Discorder Yes No Who? Lupus Yes No Who? Shingles Yes No Who? Skin Cancer Yes No Who? PhoneThis field is for validation purposes and should be left unchanged.