Medical History

Name

Date of Birth

Date

Preferred Language

Height

Weight

Race

Ethnicity

Medical Doctor

Time Since Last Health Exam

Previous Eye Doctor

Time Since Last Eye Exam

Medical History

Initial here if you DO NOT authorize us to confirm your medications through Rcopia

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

Do you have any of the following?

Do you have allergies to any medication? If yes, list them and describe reaction:

Are you pregnant or nursing?

YesNo

Do you use a computer? How many hours/day?

Do you wear Contact Lenses, or are you interested in Contacts?

Are you interested in Refractive surgery (such as LASIK)?

YesNo

For School Children Under Age 19:

Were there any complications in the prenatal, birth, or postnatal time period?

YesNo

Is the child's physical and mental development normal?

YesNo

Is the child's school performance satisfactory?

YesNo

Social History (This information is kept strictly confidential. If you wish to speak directly to the doctor, please check here. Otherwise, Select all that apply to you below:

Do you drive?Do you use tobacco? AlcoholIllegal DrugsInfected with gonorrhea or syphilisHIVHepatitisDiscomfort being around peopleSuffered any physical or mental abuseChlamydia

List any persons you wish to allow the doctor to talk to about your vision:

Family History

Have any blood relatives (parents, grandparents, siblings, children) had any of the following:

Blindness