Other:

Have you fallen in the last 12 months? YES NO

REI FORMS-2.16-P184

GlaucomaCataract

Diabetic RetinopathyMacular Degeneration

Eye InjuryDry Eye

FlashesFloaters

Smoking Status:1) Never Smoker2) Former Smoker3) Current Smoker - Everyday Smoker4) Current Smoker - Someday Smoker

BlindnessHeart DiseaseKeratoconusCataractStrokeGlaucomaCancerDiabetesThyroid DiseaseHypertensionMacular Degeneration

Has any member of your family had the following diseases? (check all that apply)

Treating Doctor’s Name:Dr. Phone: Address: Email:

REI Forms-2.16-P185

Non-Alcohol DrinkerSocial Alcohol DrinkerDrinks Alcohol Daily

Social History:

MotherMotherMotherMotherMotherMotherMotherMotherMotherMotherMother

MotherMotherMotherMotherMotherMotherMotherMotherMotherMotherMother

FatherFatherFatherFatherFatherFatherFatherFatherFatherFatherFather

FatherFatherFatherFatherFatherFatherFatherFatherFatherFatherFather

Mother Father Sister Brother Maternal GrandParent Paternal GrandParent

Caffeine UserDrug User