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Medical History Questionnaire

Name (Last, First, MI):

Birth date:

Occupation:

Daytime Phone Number:
Area Code and any extension, please:
(xxx) xxx-xxxx Ext. xxxx

Email:

Age:

Employer:

How did you hear about us?

If a doctor suggested you see us, please provide this information:

Dr's Name:

Phone:

Address:

Why are you interested in vision correction procedure? (Check all that apply)

I dislike wearing glasses.	Eyeglasses and contacts are inconvenient for sports and recreation.
I dislike my appearance with eyeglasses.	I hope to undertake a career that requires good vision (police, fire, etc.)
Contact lenses are irritating or uncomfortable.	I am concerned about functioning in an emergency.
Contact lenses are inconvenient.	I want freedom from dependency on artificial devices.
Other reasons:

Medical and Eye History

With eyeglasses or contacts on, how much nighttime glare or halos do you have?	None Minimal Mild Moderate Severe
List all eye surgeries, injuries or diseases you have had:
List all medical problems you have:
List all eye drops you use, which eye, and how often you use them:
List any medication you are allergic to:
If female, are you, or might you, be pregnant?	Yes No

Comments or Questions: