Health History Form

Do you have an allergy to latex?

List any surgeries you have had (including eye surgeries):

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.)

Hepatitis C

Has any of your immediate family members had these diseases? (father, mother, siblings, grandparents)

Does your vision limit activities of daily living (driving, reading, work, etc.)?

Have you ever had a blood transfusion?

Do you drink alcohol?

If you have any additional information you would like to add regarding medications you currently take, allergies to any medications, major illnesses, or any surgeries you may have had, please specify in the box below: