Eye History Form

 
 
 
 
Do you wear contact lenses?
 
 
 
 
 
 
Do you have trouble with distance vision?
 
 
 
 
Do you have trouble with near vision?
 
 
 
 
Do you have trouble with
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you ever been treated for any of the following: