Medical History Form

Do you have any allergies to medications:

List any medications you take (including pills, creams, drops, oral contraceptives, aspirin, over-the-counter medications, and home remedies):

List all major injuries, surgeries, and/or hospitalizations you have had:

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, bulging or protuding eyes, glaucoma, retinal disease, cataracts, eye infections, or eye injury:

Are you pregnant and/or nursing?

Do you wear glasses?

Do you wear contact lenses?

Type of contact lenses:

Are they comfortable?

Blindness

Cataract

Crossed Eyes

Glaucoma

Macular Degeneration

Retinal Detachment/Disease

Arthritis

Cancer

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Lupus

Thyroid Disease

Other