Pre-Visit Medical History Questionaire
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First Name
Last Name
Middle Initial
Contact Information
Address
City
State
Zip
Phone (Home)
Phone (Work)
Faxoptional
E-mail
Medical History
Date of Birth D: Y:
Sex
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 eyedrops 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
How did you hear about us?
How did you hear about SLV?
If a doctor recommended you see us, please provide this information:
Doctor's Name:
Phone:
Location:
What would you like to know?
Why are you interested in vision correction?
(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:
Questions/Comments?
Please use this space to ask anything.