Current Problems: Do you currently have any of the following problems?

Diabetes: Type 1 or 2?

High Blood Pressure

Heart Disease

Cancer

Arthrtitis/Lupus

Stroke

Asthma/Emphysema

Sinus

Thyroid Disease

Kidney Disease

Ulcers/Digestive

Headache/Migraine

HIV/AIDS

Fever/Weight Loss

Seasonal Allergies

Cataract

Glaucoma

Detached Retina

Diabetic Retinopathy

Macular Degeneration

Crossed Eye

Ambylopia (lazy eye)

Keratoconus

Eye Infections

Blindness

Do you smoke?

Do you drink alcohol?

Have you ever had any injury or surgery to your eyes?

Do you presently wear glasses?

Do you presently wear contact lenses?

Have you ever worn contacts?

Are you planning to get new glasses today?

Family Health History: Do/Did your parents, grandparents (maternal or paternal?), brothers, sisters or children have any of the following problems?

Diabetes

High Blood Pressure

Heart Disease

Cancer

Arthritis/Lupus

Stroke

Migraines

Thyroid Disease

Blindness

Glaucoma

Detached Retina

Diabetic Retinopathy

Macular Degeneration

Crossed Eye

Amblyopia (Lazy Eye)

Keratoconus

Do you have vision care insurance?

Do you have health (medical) insurance?

 

 
To ensure that you are a real person and not a spam robot,
please answer the following math problem: =