MEDICAL HISTORY QUESTIONAIRE*

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PAST MEDICAL HISTORY / REVIEW OF SYSTEM*





FAMILY HISTORY* - Has any blood relative ever had the following:

Cataracts:     

Diabetes:     

Glaucoma:     

Macular Degeneration:     

Retinal Detachment:     

SOCIAL HISTORY*

Do you drink alcohol?     
Do you consume caffeine?     
Do you use tobacco?  
Type of tobacco:  




Have you ever tried to quit?  






Are you passively exposed to smoke?  
Smoker Status:  
Drug Use: