General Information

Insurance Information

             VISION PLAN INFO                                  MAJOR MEDICAL INSURANCE

Eyeglass History

Do you wear glasses? *
What type of glasses do you own? *
Do you use a computer, tablet, and/or cell phone screens? *
Do you have problems with glare while driving?
Do you have problems with night vision while driving?
Are you allergic to nickel?
Do your sunglasses have UV (ultra-violet) protection?
Are your sunglasses your current prescription?

Contact Lens History

Do you currently wear contact lenses?
Have you ever tried to wear contact lenses?
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?
Are you having any problems with your current contacts?
Answer the questions below ONLY IF you currently wear contact lenses:
What is your typical contacts wearing schedule?
Would you like to be evaluated for refractive laser surgery?

Medical History

Do you suffer from: *
Light Sensitivity?
Tired Eyes?
Amblyopia (lazy eye)?
Epiphora (excess tearing)?
Eye Pain or Soreness?
Foreign Body Sensation?
Infection of Eye or Lid?
Mucous Discharge?
Ptosis (drooping eyelid)?
Sandy or Gritty Feeling?
Strabismus (crossed eyes)?
Blurred Distance Vision?
Blurred Near Vision?
Distorted Vision (haloes)?
Double Vision?
Floaters or Spots?
Fluctuating Vision?
Loss of Vision?
Loss of Side Vision?
Many diseases of the body have grave eye health consequences.  While the questions below may seem unrelated to your eye health, it is crucial to your care that we ask them.
Have you ever been treated for any MEDICAL CONDITIONS?
   (e.g., diabetes, high blood pressure, arthritis) *

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? *

Do you have any food or drug ALLERGIES? *
Do you currently have any of the following: *
Chronic fever / unexpected weight loss or gain / fatigue?
Ear/Nose/Throat problems (e.g., hearing loss, sinus problems, sore throat?)
Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands/feet?
Respiratory problems (e.g., shortness of breath, wheezing, coughing)?
Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomiting)?
Genitournimary 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 much of the time)?
Blood/Lymph problems (e.g., bruising, weakness, unusual paleness, swollen glands
Immune problems (e.g., frequent infections; allergic reactions to foods, dust, pollens)?

Family/Social History

Do any MEDICAL (such as cancer, diabetes, HBP) or EYE DISEASES (such as cataracts, glaucoma, macular degeneration) run in your family (blood relatives only)? *

Do you consume alcohol? *
Do you smoke? *
What is your Marital Status? *