Patient Health History UpdateHomePatient Health History Update English Arabic Chinese (Simplified) English French German Italian Korean Spanish Please answer all the questions below. 1. Do you have or have you ever had any of the following? 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 If yes, please 3. Have you ever had any surgery on your eye(s) YesNo If yes, please indicate type of surgery, to which eye and date of surgery 4. Please list any prescription and non-prescription eye drops you are using 7. Are you in good health now? YesNo 8. Are you now under the care of a physician? YesNo If yes, what is the condition being treated? 9. Have you ever been hospitalized or had a serious illness? YesNo If yes, please explain 10. (Women) Are you pregnant? YesNo If so, please provide due date 11. Do you use tobacco in any form? YesNo If yes, how much 12. Do you use alcoholic beverages (more than 2 drinks per day)? YesNo 13. Do you drive YesNo 14. Do you have or have you ever had any of the following? 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 Δ