Medical History Medical History Name First Last Date Date Format: MM slash DD slash YYYY Date of Birth Date Format: MM slash DD slash YYYY When was your last eye Exam?Do you wear glasses?YesNoIf you wear glasses, what do you use them for?DistanceComputerNearFull-TimePart-timeDo you wear contact lenses?YesNoIf you wear contact lenses how many days a week? What Brand?Please list any prescription or non prescription medications you are taking Please list any prescription or non prescription eye drops you are using YOUR OCULAR HISTORY Please give details on any YES answer.History of Eye Injury.YesNoexplainHistory of Eye InfectionYesNoexplainHistory of Eye DiseaseYesNoexplainHistory of Eye TurnYesNoexplainHistory of Eye SurgeryYesNoexplainHistory of Eye Surgery (Give dates if possible) Date Format: MM slash DD slash YYYY Do you have a family history of Macular Degeneration? If Yes who in the family?Do you have a family history of Glaucoma? If Yes who in the family?Do you smoke? If Yes how many packs per day?Do you drink alcohol?Do you have any communicable disease?If female, are you pregnant or nursing?Yes pregnantYes nursingYes bothNoDue Date if pregnant Date Format: MM slash DD slash YYYY PERSONAL MEDICAL HISTORYPlease check whether there is a history of problems in each category.CancerYesNoAllergies (Seasonal / Year round / Medications)YesNoCardiovascular C High Blood Pressure / Heart Disease / Circulation Problem / Stroke)YesNoConstitutional difficulties (general feeling of wellness)YesNoDiabetes (Yr Diagnosed)/ Increased Cholesterol/Gout/Low Thyroid/HyperthyroidYesNoGastrointestinal/StomachYesNoGenitourinaryYesNoHead (Ear/Nose/Throat Disorder/Headaches/Migraines/Sinus Problems)YesNoBlood Disease/LymphaticYesNoImmunologicYesNoSkinYesNoMusculoskeletal/ArthritisYesNoNeurologicalYesNoPsychiatric/DepressionYesNoRespiratoryYesNoOtherYesNo