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Erker’s Fine Eyewear

MM slash DD slash YYYY
MM slash DD slash YYYY
Address:*
Do you wear glasses now?*
Do you wear contacts now?*

Personal Medical History

Do you currently or have you ever had health problems in the following areas:
Constitutional (sudden weight gain or loss)*
Genitourinary disease (bladder, kidney)*
Skin disease*
Respiratory disease (Asthma, COPD)*
Neurologic problems (headaches, seizures)*
Bones, Joint disease*
Endocrine (thyroid or other gland disease)*
Allergy, Immunologic disease*
Cancer*
Blood disease (Anemia, Sickle Cell)*
Gastrointestinal disease*
Mental Health disease*
Vascular/Cardiovascular
Diabetes*
Eye Injuries*
High Blood Pressure*
Eye surgery*
Heart disease*
Eye diseases*

Family Medical History

Is there a history in your family (parents, siblings) of any of the following diseases:
Blindness*
Diabetes*
Glaucoma*
High Blood Pressure*
Macular Degeneration*
Heart disease*
Retinal disease*
Thyroid disease*