Patient Medical History Name: First Last Date of Birth: Date Format: MM slash DD slash YYYY Exam Date: Date Format: MM slash DD slash YYYY Exam InformationDo you currently wear glasses?YesNoIf so, how old are they?Are you interested in any of the following? Contact Lenses LASIK Surgery Do you currently wear contact lenses?YesNoIf so, how old are they?Have you ever had LASIK Surgery?NoYesIf yes, year:Previous Eye PhysicianDate of Last Eye Exam Date Format: MM slash DD slash YYYY Last Date of Dilation Date Format: MM slash DD slash YYYY Primary Care PhysicianDate of Last Visit Date Format: MM slash DD slash YYYY Eye ConcernsHave you and/or your family been treated for any of the following conditions?SelfParentSiblingCataractsMacular DegenerationGlaucomaDiabetic RetinopathyColor DeficiencyHave you had a history of any of the following? Dry Eye Eye Infection Floaters/Flashes Iritis/Uveitis Retinal Defects Lazy Eye Are you currently experiencing any of the following eye/vision concerns? Floaters Flashes of Light Itching Tired Eyes Dryness/Burning Redness If you are experiencing blurry vision, where specifically? Near (i.e. reading) Intermediate (i.e. computer) Distance (i.e. driving) Are there ANY other eye conditions/ concerns we should be aware of?(i.e. any eye surgeries) Medical HistoryHave you and/or your family been treated for any of the following conditions?SelfParentSiblingCancerHypertensionMigrainesHeart DiseaseStroke/CVADiabetesEpilepsyArthritisGastrointestinal DiseaseMental IllnessAutoimmune DiseaseIf Autoimmune Disease, what type?If Diabetes, what type?Year Diabetes diagnosedIf you answered yes to any of the above, please explain belowAre there any other medical conditions/concerns we should be aware of?(i.e. major surgeries)Please List Current Medications Are you allergic to any medications or have any other allergies?