I Care for Eyewear
Ocular History Family Ocular and Systemic History-please
Do you wear Glasses ___Yes ___No indicate in the blank who in your family has the
Do you wear Contact Lenses ___Yes ___No condition:
If YES what type do you wear Cataract:_______________________________________
Gas Permeable ___Yes ___No Glaucoma:_____________________________________
Disposable soft ___Yes ___No Macular Degeneration:________________________
If NO are you interested? ___Yes ___No ______________________________________________
History of Present Illness
Are you currently experienceing any of the following: Ocular Surgery
Blurred Distance Vision ___Yes ___No Have you had eye surgery? ___Yes ___No
Blurred Near Vision ___Yes ___No If YES what type of surgery?___________________
Burning Eyes ___Yes ___No ________________________________________________
Double Vision ___Yes ___No ________________________________________________
Dry Eyes ___Yes ___No
Eye Strain ___Yes ___No Medications: List all current medications attach
Flashes of Light ___Yes ___No additional sheet if needed:
Gritty Eyes ___Yes ___No ________________________________________________
Headaches ___Yes ___No ________________________________________________
Itchy Eyes ___Yes ___No ________________________________________________
Loss of Vision ___Yes ___No ________________________________________________
Night Vision Problems ___Yes ___No ________________________________________________
Objects Floating in Vision ___Yes ___No ________________________________________________
Pain in Eyes ___Yes ___No Allergies
Red Eyes ___Yes ___No Are you allergic to medications: ___Yes ___No
Sensitivity to Light ___Yes ___No If YES please list:
Watery Eyes ___Yes ___No _______________________________________________
Patient History _______________________________________________
Blindness ___Yes ___No _______________________________________________ Cataract ___Yes ___No Do you have any other Allergies?___Yes ___No
Glaucoma ___Yes ___No If YES please list:
Macular Degeneration ___Yes ___No ________________________________________________
Retinal Detachment/Disease ___Yes ___No _______________________________________________
High Blood Pressure ___Yes ___No _______________________________________________
Thyroid Dysfunction/Disease ___Yes ___No _______________________________________________
Diabetes ___Yes ___No
If Yes what is your last A1C reading_______________ _______________________________________________
Your Doctor's Name and Location(Town and State) Signature
Do you wear Glasses ___Yes ___No indicate in the blank who in your family has the
Do you wear Contact Lenses ___Yes ___No condition:
If YES what type do you wear Cataract:_______________________________________
Gas Permeable ___Yes ___No Glaucoma:_____________________________________
Disposable soft ___Yes ___No Macular Degeneration:________________________
If NO are you interested? ___Yes ___No ______________________________________________
History of Present Illness
Are you currently experienceing any of the following: Ocular Surgery
Blurred Distance Vision ___Yes ___No Have you had eye surgery? ___Yes ___No
Blurred Near Vision ___Yes ___No If YES what type of surgery?___________________
Burning Eyes ___Yes ___No ________________________________________________
Double Vision ___Yes ___No ________________________________________________
Dry Eyes ___Yes ___No
Eye Strain ___Yes ___No Medications: List all current medications attach
Flashes of Light ___Yes ___No additional sheet if needed:
Gritty Eyes ___Yes ___No ________________________________________________
Headaches ___Yes ___No ________________________________________________
Itchy Eyes ___Yes ___No ________________________________________________
Loss of Vision ___Yes ___No ________________________________________________
Night Vision Problems ___Yes ___No ________________________________________________
Objects Floating in Vision ___Yes ___No ________________________________________________
Pain in Eyes ___Yes ___No Allergies
Red Eyes ___Yes ___No Are you allergic to medications: ___Yes ___No
Sensitivity to Light ___Yes ___No If YES please list:
Watery Eyes ___Yes ___No _______________________________________________
Patient History _______________________________________________
Blindness ___Yes ___No _______________________________________________ Cataract ___Yes ___No Do you have any other Allergies?___Yes ___No
Glaucoma ___Yes ___No If YES please list:
Macular Degeneration ___Yes ___No ________________________________________________
Retinal Detachment/Disease ___Yes ___No _______________________________________________
High Blood Pressure ___Yes ___No _______________________________________________
Thyroid Dysfunction/Disease ___Yes ___No _______________________________________________
Diabetes ___Yes ___No
If Yes what is your last A1C reading_______________ _______________________________________________
Your Doctor's Name and Location(Town and State) Signature