Please answer all the questions below.


    Cataracts: YesNo
    Glaucoma: YesNo
    Macular degeneration: YesNo
    Corneal disease: YesNo
    Lazy Eye: YesNo
    Retinal problems: YesNo
    Diabetes: YesNo
    Do you take Insulin?: YesNo
    High blood pressure: YesNo
    Heart disease: YesNo
    Asthma: YesNo
    Arthritis: YesNo
    Thyroid disease: YesNo
    Stroke: YesNo
    Cancer: YesNo
    Migraine headaches: YesNo
    Seasonal allergies: YesNo
    Wear contact lenses: YesNo
    Family history of diabetes: YesNo
    Family history of glaucoma: YesNo
    Family history of heart disease: YesNo
    Family history of cancer: YesNo
    2. Have you ever had an injury to your eye(s) YesNo


    3. Have you ever had any surgery on your eye(s) YesNo



    7. Are you in good health now? YesNo
    8. Are you now under the care of a physician? YesNo


    9. Have you ever been hospitalized or had a serious illness? YesNo


    10. (Women) Are you pregnant? YesNo


    11. Do you use tobacco in any form? YesNo


    12. Do you use alcoholic beverages (more than 2 drinks per day)? YesNo
    13. Do you drive YesNo

    GENERAL
    Tire easily, weakness: YesNo
    Marked weight change: YesNo
    Night sweats: YesNo
    Persistent fever: YesNo
    SKIN
    Eruptions (rash) hives: YesNo
    Change in skin color: YesNo
    EARS
    Loss of hearing: YesNo
    Ringing in ears: YesNo
    NOSE
    Frequent nosebleeds: YesNo
    Sinus problems: YesNo
    THROAT
    Soreness/horseness: YesNo
    NERVOUS SYSTEM
    Stroke: YesNo
    Headaches: YesNo
    Convulsions/epilepsy: YesNo
    Numbness/tingling: YesNo
    Dizziness/fainting: YesNo
    Psychiatric treatment: YesNo
    RESPIRATORY
    Tuberculosis: YesNo
    Emphysema: YesNo
    Hay fever: YesNo
    Persistent cough: YesNo
    Sputum production (phlegm): YesNo
    Cough up bloody sputum: YesNo
    Difficulty breathing while lying down: YesNo
    Asthma: YesNo
    BARRIERS TO TREATMENT
    Visual Impairment: YesNo
    Difficulty Hearing: YesNo
    Any language barrier: YesNo
    Any cultural barriers to receiving treatment : YesNo
    Any religious barriers to receiving treatment : YesNo
    HEART/BLOOD VESSELS
    Rheumatic fever: YesNo
    Heart murmur: YesNo
    Chest pain/discomfort YesNo
    Heart attack YesNo
    Shortness of breath YesNo
    Swelling of ankles YesNo
    Heart Surgery YesNo
    BONE/MUSCLES
    Rheumatism: YesNo
    Artificial joints/limbs: YesNo
    DIGESTIVE SYSTEM
    Hepatitis: YesNo
    Jaundice: YesNo
    Ulcers: YesNo
    Change in appetite: YesNo
    Black, bloody or pale stools: YesNo
    URINARY
    Kidney disease: YesNo
    Increase in frequency of urination (night): YesNo
    Burning on urination: YesNo
    Urethral discharge: YesNo
    Bloody urine: YesNo
    BLOOD
    Bruise easily: YesNo
    Anemia: YesNo
    Blood transfusion: YesNo
    OTHER
    Radiation therapy: YesNo
    Chemotherapy: YesNo
    Tumors of growths: YesNo
    HIV+: YesNo
    AIDS: YesNo
    Do you have an Advance Directive or Living Will?: YesNo