Marital Status*:

Do you wear glasses?*

Do you wear contact lenses?*

Have you had LASIK surgery?*

Are you sensitive in bright sunlight?*

Do you perform fine or close-up work?*

Do you have trouble reading signs when driving at night?*

Are you outdoors all or part of the time?*

Are you bothered by the glare from overhead lighting?*

Is safety protection a concern at work?*

Are you bothered by the glare from a computer screen?*

Loss of Vision*

Burning*

Blurred of Vision*

Foreign Body Sensation*

Distorted Vision*

Excess Tearing / Watering*

Loss of Side Vision*

Glare / Light Sensitivity*

Double Vision*

Eye Pain or Soreness*

Dryness*

Chronic Infection of Eye / Lid*

Mucous Discharge*

Sty or Chalazion*

Redness*

Flashes / Floaters in Vision*

Sandy or Gritty Feeling*

Tired Eyes / Eye Strain*

Itching*

Glaucoma*

Retinal Detachment*

Cataracts*

Macular Degeneration*

Ears, Nose, Mouth, Throat

Allergies / Hay Fever*

Sinus Congestion / Dry Throat or Mouth*

Runny Nose / Chronic Cough*

Bones / Joints / Muscles

Rheumatoid Arthritis*

Muscle Pain / Joint Pain*

Allergic / Immunologic*

Respiratory

Asthma / Bronchitis*

Chronic Bronchitis*

Emphysema*

Cancer*

Skin (Integumentary)*

Psychiatric*

Vascular / Cardiovascular

Diabetes / Heart Pain*

High Blood Pressure / Vascular Disease*

Gastrointestinal*