Prefix Mr. Mrs. Ms Miss Dr. Rev. Prof
Preferred language* English Spanish French Japanese Decline to specify
Race* American_Indian or Alaskan Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Decline to specify
Ethnicity* Decline to specify Hispanic or Latino Native Hawaiian or Pacific Islander Not Hispanic or Latino
Communication Preferrence Email Postal Telephone
No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
If you have any comments you would like to add, please enter them here.
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