Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

How many hours a day are you on your phone/computer?

0-4 hours

4-8 hours

8-12 hours

12+ hours

Health Conditions (check all that apply)

Ear/Nose/Throat

Cardiovascular

Mental

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Intergumentary (skin)

Nervous System

Endocrine (glands)

Blood/Lymph

Allergic/Immune

Do you smoke? *

Yes

No

Family History *

Glaucoma

Macular Degeneration

Cataracts

Retinal Detachment

Strabismus (eye turn)

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Problems

Cancer

Unknown

N/A

Other (please explain below)

Do you wear prescription glasses? *

*Please bring in your most recent pair/s or written prescription/s*

Yes

No

Our doctors are certified to co-manage LASIK/ implantable contact lens refractive surgery AND cataract surgery. Would you like to find out if you are a candidate for any of these vision correction treatments?

Yes

No

Date *

MM

DD

YYYY