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Do you currently have any medical conditions? Any current medications?

Any environmental or medication related allergies?

Do you have a history of any eye conditions or vision problems?

This information is HIPPA protected. Substance abuse can affect your eye health. 

Any health or eye related problems your parents or siblings have experienced.

General vision better worse or the same 

Blurry vision (far, near, arms length)

Dim or dark vision

Increased glare

Flashes or floaters in vision

Increased headaches

Double vision

Decreased peripheral vision

Pain with eye movement

Decreased depth perception

Itchy

Burning

Redness

Dry 

Light sensitivity

Discharge (mucous or watery)

Eyestrain or ache 

Flashes or floaters

Headaches

Pain with eye movement 

Double vision 

Decreased peripheral vision