Health History Form Name(Required) First Last Date(Required) MM slash DD slash YYYY MEDICATIONS – Include any eye drops, pills, creams, insulin, aspirin, vitamins, supplements, or OTC meds. Please list below or provide a current list.EYE HISTORYCataracts(Required) Yes No Surgeries/Procedures(Required) Glaucoma Yes No Surgeries/Procedures(Required) Eyelids(Required) Yes No Surgeries/Procedures(Required) Cornea(Required) Yes No Surgeries/Procedures(Required) Retina(Required) Yes No Surgeries/Procedures(Required) Muscle(Required) Yes No Surgeries/Procedures(Required) Laser(Required) Yes No Surgeries/Procedures(Required) Injuries(Required) Yes No Surgeries/Procedures(Required) (Required) ALLERGIES – Include drugs, latex, or adhesive tapesFAMILY MEDICAL HISTORYAdopted(Required) Yes No Relationship to you(Required) Blindness(Required) Yes No Relationship to you(Required) Cataract(Required) Yes No Relationship to you(Required) Glaucoma(Required) Yes No Relationship to you(Required) Macular degeneration(Required) Yes No Relationship to you(Required) Retinal disease(Required) Yes No Relationship to you(Required) Retinal detachment(Required) Yes No Relationship to you(Required) Eye turn(Required) Yes No Relationship to you(Required) Heart disease(Required) Yes No Relationship to you(Required) Diabetes(Required) Yes No Relationship to you(Required) Cancer(Required) Yes No Relationship to you(Required) PERSONAL MEDICAL HISTORYHeart problems(Required) Yes No Type of Condition/Surgeries(Required) High blood pressure(Required) Yes No Type of Condition/Surgeries(Required) High cholesterol(Required) Yes No Type of Condition/Surgeries(Required) Stomach problems(Required) Yes No Type of Condition/Surgeries(Required) Kidney/Urinary problems(Required) Yes No Type of Condition/Surgeries(Required) Sinus problems(Required) Yes No Type of Condition/Surgeries(Required) Headaches/Migraines(Required) Yes No Type of Condition/Surgeries(Required) Unusual bleeding(Required) Yes No Type of Condition/Surgeries(Required) Diabetes(Required) Yes No Yaer:(Required)Type of Condition/Surgeries(Required) Thyroid problems(Required) Yes No Type of Condition/Surgeries(Required) Arthritis(Required) Yes No Type of Condition/Surgeries(Required) Back problems(Required) Yes No Type of Condition/Surgeries(Required) Skin problems(Required) Yes No Type of Condition/Surgeries(Required) Cancer(Required) Yes No Type of Condition/Surgeries(Required) Stroke(Required) Yes No Year:(Required)Type of Condition/Surgeries(Required) Tremors/Seizures(Required) Yes No Type of Condition/Surgeries(Required) Breathing problems(Required) Yes No Type of Condition/Surgeries(Required) Sleep apnea(Required) Yes No Type of Condition/Surgeries(Required) Currently pregnant(Required) Yes No Type of Condition/Surgeries(Required) SOCIAL HISTORYDo you use tobacco products?(Required) Yes No Amount/how long?(Required) Have you smoked in the past?(Required) Yes No Quit when?(Required) Do you drink alcohol?(Required) Yes No Drinks per week?(Required) Do you drink caffeine?(Required) Yes No Cups per day?(Required) Do you wear eyeglasses?(Required) Yes No Please check one:(Required) single vision bifocals trifocals progressives OTC readers Do you wear contact lenses?(Required) Yes No Please check one:(Required) Soft lenses Hard lenses