General Information


Do you experience any of the following?

Eyeglass History

Do you wear glasses? *
Do you use a computer? *
Are you interested in contact lens wear? *

Medical History

Have you ever had any EYE DISEASE? (e.g., glaucoma,
cataracts, wandering or "lazy" eye, retinal detachment) *

Have you ever had any SURGERY for your eyes or any other condition? *

Do you take any MEDICATIONS (including vitamins/supplements)? *

Do you have any drug or food ALLERGIES? *

Do you currently have any of the following conditions?
Allergic/Immunologic (e.g. Drug Allergy, Rheumatoid Arthritis, Lupus)? *
Musculoskeletal (e.g. Fibromayalgia, Osteoarthritis, Anklyosis Spondylitis)? *
Cardiovascular (e.g., Heart Disease, Hypertension, Stroke, Vascular disease)? *
Gastrointestinal (e.g. Crohn's, Colitis, Ulcer, Digestive)? *
Neurological (e.g., MS, Epilepsy, Alzheimers, Parkinsons)? *
Constitutional (e.g., Developmental Disability, Weight Loss, Fever, Fatigue, Trauma)? *
Genitourinary (e.g. STD, Viral Herpetic, Chlamydia)? *
Psychiatric (e.g., Depression, Panic Disorder)? *
Ear, Nose, Mouth & Throat (e.g., Ear Ache, Sore Throat, Tinnitis)? *
Hematologic/Lymphatic (e.g., Anemia, Leukemia, Large Blood Loss)? *
Respiratory (e.g., Asthma, Bronchitis, Emphysema)? *
Endocrine (e.g., Diabetes, Thyroid, Hormonal dysfunction)? *
Integumentary (e.g., Eczema, Rosacea, Psoriasis)? *

Family/Social History

Do you consume alcohol? *
Do you smoke? *