Patient Forms"*" indicates required fields Erker’s Fine EyewearName:*Age:*Date of Birth:* MM slash DD slash YYYY Date:* MM slash DD slash YYYY Address:* Street Address City State / Province / Region ZIP / Postal Code Phone:*Email:* Occupation:*Do you wear glasses now?* Yes NoDo you wear contacts now?* Yes NoPersonal Medical HistoryMedications:*Medications Allergies:*Do you currently or have you ever had health problems in the following areas:Constitutional (sudden weight gain or loss)* No YesGenitourinary disease (bladder, kidney)* No YesSkin disease* No YesRespiratory disease (Asthma, COPD)* No YesNeurologic problems (headaches, seizures)* No YesBones, Joint disease* No YesEndocrine (thyroid or other gland disease)* No YesAllergy, Immunologic disease* No YesCancer* No YesBlood disease (Anemia, Sickle Cell)* No YesGastrointestinal disease* No YesMental Health disease* No YesVascular/CardiovascularDiabetes* No YesEye Injuries* No YesHigh Blood Pressure* No YesEye surgery* No YesHeart disease* No YesEye diseases* No YesIf you answered Yes to any of the above questions, please explain or discuss with the doctorFamily Medical HistoryIs there a history in your family (parents, siblings) of any of the following diseases:Blindness* No YesDiabetes* No YesGlaucoma* No YesHigh Blood Pressure* No YesMacular Degeneration* No YesHeart disease* No YesRetinal disease* No YesThyroid disease* No Yes