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«About your first appointment Please arrive approximately 10 to 15 minutes early for your first appointment. You may wish to arrive even earlier in ...»

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Do you wear glasses? No Yes If yes, how old is your present pair of lenses? _________________

Do you wear contact lenses? No Yes If yes, how old is your present pair of lenses? _________________

Brand and power of current contact lenses: _________________________________________________________

If you do not already wear contacts, are you interested in wearing contact lenses? Yes No

–  –  –

Please list any prior eye surgeries (including dates):

_____________________________________________________________________________________________

Please list any eye-related medications (including over-the-counter) that you use:

_____________________________________________________________________________________________

Medical History Primary Care Provider____________________________ Last Visit ____/____/____ Phone (_____) _____________

Are you pregnant and/or nursing? No Yes

Do you have any allergies to medications? No Yes If yes, explain:

_____________________________________________________________________________________________

–  –  –

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

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Medications (include dosages):

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

–  –  –

If you answered YES to any of the above or have a condition not listed, please explain:



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