Medical History

1

Name* This field is required.

First Name

Last Name

2

What brings you into the office?* This field is required.

Misalignment of the eyes

Double vision

Difficulty seeing

Other

3

Is there a history of glasses wear in the past* This field is required.

YESNO

4

Please specify for how long and how old are current glasses

5

Any history of patching or prism use?* This field is required.

YESNO

6

Please specify

7

Any history of eye surgery* This field is required.

YESNO

8

Please specify: date of surgery, type of surgery and which eye

9

Any other eye problems?

10

Any medical problems?* This field is required.

YESNO

11

Please specify

12

Current medications?* This field is required.

YESNO

13

Please list prescription and over the counter meds

14

Any allergies* This field is required.

YESNO

15

Please specify

17

Tobacco use?* This field is required.

YESNO

18

Alcohol use?* This field is required.

YESNO

19

Use of drugs or other substances* This field is required.

YESNO