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Medical Registration Form

So that we can get an idea of your state of health, please fill out the questions below.

7. Separate invoice copy?
8. Are you currently pregnant?
> Are you still breast-feeding?
9. Your Symptoms?
10. Last Medicinal Eye-Check?
11. Do you have a contagious disease? (Hepatitis, MRSA, etc.)
12. Have you any allergies?
13. Are you diabetic?
> Is you blood sugar stable?
> Do you treat it with:
> You participate a diabetes-management program?
14. You have thyroid disease?
15. Do you have high blood-pressure?
16. Have you ever had a heart attack?
17. Have you ever had a stroke?
18. Do you take blood-thinning medication?
19. Do you take prostate medication Tamsulosin?
20. Any family eye diseases?
21. Did you have an eye injury?
22. As a child, did you always see well with both eyes?
23. Have you ever been cross-eyed?
24. Do you require a prescription?
25. Do you wear contact lenses?
26. Your last lens fitting/check?
27. Have you ever had laser surgery or been operated on before?
28. Do you use eye-drops?
29. Do you take any medication regularly?
30. I request further information about:

Thank you!

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