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