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Patient Information

Patient Name *
Date *
Are you interested in Refractive Surgery (LASIK, Intacs)? *
Are you interested in Contact Lenses? *
If yes, contact lens experience:
Current Eye Problems
Do you currently have any problems in the following areas? For each area, indicate Yes or No. If "Yes", please provide an explanation.
Glaucoma, cataract, retinal disease, etc.
Double vision
Decreased or blurred vision spells
Eye pain
Floaters in your vision
Flashing lights
Eye injury
Serious eye infection
Dryness
Sandy or gritty feeling
Redness
Mucous discharge
Itching
Burning
Glare / light sensitivity
Drooping eyelid
In or out turning of eye / lazy eye
Family History
Please indicate if any family members (Mother, Father, Sister, Brother, Daughter, Son) have a history of the following conditions. If yes, please provide their relationship to you.
Family History: Glaucoma
Family History: Diabetes
Family History: Macular Degeneration
Social History
Do you drink alcohol? *
If yes, how often do you drink?
Do you smoke? *
If yes, how much do you smoke?