Adult Form

For persons 18 years of age or older


Important: All text fields with a red label are required information.

Patient's Name:

last	first	middle


	List any major illnesses or injuries, especially eye injuries:


	List any operations the patient has had:

Your Pharmacy

Please tell us if you have a preferred Pharmacy, their location and their phone number.

Has the patient been treated for any of the following? (choose YES or NO)

Ear, Nose, Throat		Endocrine
Sinus:		Diabetes:
Ear Infection:		Thyroid:

Neurological		Lungs
Headache:		Bronchitis:
Seizures:		Emphysema:
Stroke:

Allergic		Gastrointestinal
Hay Fever:		Ulcers:
Skin Rash:		Intestinal Problems:

Psychiatric		Skin Rash:
Depression:
Anxiety:

Cardiovascular Problems:		Muscles, Bones or Joints:
Heart:		Arthritis:
Vessels:

Genital, Kidney or Bladder:

Comments or other illness not listed:


	List any current medication:


	List any allergies, especially medications:


Is there a family history of any of the following? (choose YES or NO)
Cataracts under age 40:						Difficulty with anesthesia:
Eye muscle problems:						Retinal problems:
Very strong glasses:						Neurological problems:
Glaucoma under age 40:						Blindness: