1. Rank: Name: Age: Duty Phone: Home Phone:Box #:Last eye exam? List approximate year ____________Last time your eyes were dilated? List approximate year ____________Are you on PRP status? FORMCHECKBOX Yes FORMCHECKBOX No Are you on Flying status? FORMCHECKBOX Yes FORMCHECKBOX NoWill you be deploying in the next 3 months? FORMCHECKBOX Yes FORMCHECKBOX NoReason for visit (please circle one) Routine Exam / Vision ProblemIf vision problem, please explain in detail below:Do you wear glasses? FORMCHECKBOX Yes FORMCHECKBOX No --If “YES” for what purpose? Distance / Reading / BothDo you wear contact lenses? FORMCHECKBOX Yes FORMCHECKBOX NoList contact lens brand____________ Brand of lens solution used:____________How often replaced__________ Hours worn per day_______ Current medications you are taking (please list)Do you have any allergies to medications? FORMCHECKBOX Yes FORMCHECKBOX No--If “Yes” please list medications:Have you had any Eye Disease / Injury / Surgery? FORMCHECKBOX Yes FORMCHECKBOX No--If “Yes” please explain.Present Occupation / Hobbies:Do you use a computer: FORMCHECKBOX Yes FORMCHECKBOX NoPlease estimate the number of hours per day: ________<br />Office Use Only<br />DVA sc/cc 20/ PH 20/ NCT OD______@ FOC:<br /> 20/ 20/ OS______ <br />C.L. Rx OD GMI: M50 <br /> OS <br /> BEP:<br /> <br /> ORTHO:<br />Personal Medical History Please Check Family Medical History Please CheckDo you have…? If “YES” please explain Yes No Do your grandparents/parents/siblings have If “YES” please explain Yes No Allergies of Hayfever FORMCHECKBOX FORMCHECKBOX Amblyopia lazy eye FORMCHECKBOX FORMCHECKBOX If “YES”, who?Amblyopia lazy eye FORMCHECKBOX FORMCHECKBOX Asthma FORMCHECKBOX FORMCHECKBOX Crossed Eye / Wall Eye FORMCHECKBOX FORMCHECKBOX If “YES”, who?Cataracts FORMCHECKBOX FORMCHECKBOX Crossed Eye / Wall Eye FORMCHECKBOX FORMCHECKBOX Diabetes FORMCHECKBOX FORMCHECKBOX If “YES”, who?Double Vision FORMCHECKBOX FORMCHECKBOX Diabetes FORMCHECKBOX FORMCHECKBOX Eye Surgery FORMCHECKBOX FORMCHECKBOX If “YES”, who?Skin disorders? FORMCHECKBOX FORMCHECKBOX Glaucoma FORMCHECKBOX FORMCHECKBOX Glaucoma FORMCHECKBOX FORMCHECKBOX If “YES”, who?Heart Disease FORMCHECKBOX FORMCHECKBOX High Blood Pressure FORMCHECKBOX FORMCHECKBOX Heart Disease FORMCHECKBOX FORMCHECKBOX If “YES”, who?Sinus Problems FORMCHECKBOX FORMCHECKBOX Thyroid Disease FORMCHECKBOX FORMCHECKBOX High Blood Pressure FORMCHECKBOX FORMCHECKBOX If “YES”, who?Do you Smoke? FORMCHECKBOX FORMCHECKBOX Hematologic disorders? FORMCHECKBOX FORMCHECKBOX Muscle/bone disorders? FORMCHECKBOX FORMCHECKBOX If female, are you pregnant?Gastrointestinal problems? FORMCHECKBOX FORMCHECKBOX Frequent/RecurringHeadaches (if yes, answer below) FORMCHECKBOX FORMCHECKBOX <br />Headache/Pain Scale (1 to 10): _______ When did it first start:_______<br />Location: __________________ <br />How long does it last: ______________________<br />Frequency: ________________<br />Increases with what type of activity: ______________________<br />What makes it go away: ____________________<br />