Current Primary Care Physician (if you do not have one, leave blank)

First Name

Last Name

Phone number of current primary care physician (if you do not have one, just leave blank)

(###)

###

####

Date of Last Eye Exam

MM

DD

YYYY

I wear the following to correct my vision:

Glasses

Contacts

I am legally blind but do not utilize assistive equipment

I am legally blind and use assistive equipment

Other

I do not require vision correction

Date of Last Dental Visit

MM

DD

YYYY

I wear one of the following

Braces

Retainers

Mouth Guard

Dentures

Implants

None

Currently, with regard to my mental health:

I AM MENTALLY STABLE

I FEEL AS THOUGH I AM STRUGGLING SOME PSYCHOLOGICALLY

I FEEL AS THOUGH I AM STRUGGLING A LOT PSYCHOLOGICALLY

OTHERS ARE WORRIED ABOUT MY CURRENT BEHAVIOR OR MENTAL HEALTH