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