Name
Date of Birth
Date
Referring Doctor
Regular/Primary Care Doctor
What is the reason for your visit today?
Which eye is this for? LeftRightBoth
Symptoms
What other symptoms do you have? (Mark all that apply)
Blurred visionFluctuation in visionDouble visionFlashesFloatersLight SensitivityPainVision lossOther
How long have you been experiencing these problems?
Unsure1-2 days3-5 days1 week2-3 weeks1 month3 months6 months1 yearLong term
What are your other eye problems? (Mark all that apply)
AMD (macular degeneration)Diabetic retinopathyRetinal detachmentCataractsGlaucomaBlocked vein or artery in the eyeOther
Medical History
Do you have diabetes? NoType 1Type 2
How many years have you had it?
What is your A1C level?
Please mark any medical problems you have:
AIDS/HIVAlcoholismAlzheimer’sAnemiaArthritisAsthmaCancerCerebral palsyDementiaGoutHeart diseaseHigh cholesterolHypertensionKidney diseaseMigrainesParkinson’sSeizuresThyroidOther
Have you had any of the following eye surgeries? (Mark all that apply and the corresponding eye)
Cataract Surgery Right
Cataract Surgery Left
Glaucoma Surgery Right
Glaucoma Surgery Left
LASIK Surgery Right
LASIK Surgery Left
Retina Surgery Right
Retina Surgery Left
Please list all past non-ocular surgeries:
Please list all medications/eye drops you currently use:
Family Medical History
Family medical history (Mark all that apply):
AMD (macular degeneration)Arthritis or rheumatismBlindness/low visionCoronary artery diseaseDiabetesHeadaches/migrainesHeart diseaseHigh cholesterolHypertensionKidney diseaseStrokeThyroid disease
Do you smoke? Never smokerOccasional smokerLight smokerHeavy smoker
Do you drink alcohol? NeverOccasionally/Socially1-2 drinks per day3-4 drinks per day
Do you use street drugs? YesNo
Are you currently under hospice care? YesNo
Review of Systems
Please mark all that you are currently experiencing
None of the below (All systems normal)
Allergy/Immunology
Autoimmune diseaseSeasonal allergies
Cardiovascular
Chest painShortness of breathSwelling of the feetShortness of breath when lying flatRacing pulseIrregular heartbeat
Constitutional
FeverWeight lossFatigueLoss of appetiteChillsNight sweatsFeel sickPoor appetite
Endocrine
Excess thirstExcessive urinationHeat intoleranceCold intoleranceHair lossDry skin
Gastrointestinal
Abdominal painNausea DiarrheaBloody stoolsStomach ulcersConstipationTrouble swallowingGastrointestinal ulcersJaundice or yellow skin
Genitourinary
Pain/burning on urinationBlood in urineBladder troubleDialysisGenital sores or ulcersKidney failureKidney problemsKidney stonesProstatitisTesticular painUrinary discharge
Hematology/Oncology
Easy bruisingProlonged bleeding
Head/Ears/Nose/Throat (HENT)
Hearing lossSore throatRunny noseDry mouthJaw claudication (pain chewing)Earache
Integumentary
RashChange in moleSkin soresSkin cancerSevere itching
Musculoskeletal
Muscle achesJoint painDifficulty lying flatBack pain during/after sleep
Neurological
WeaknessHeadachesScalp tendernessDizzinessParalysis of extremitiesTremorStrokeNumbnessTinglingSeizures or convulsionsFaintingMemory loss
Psychiatric
ADHDAnxietyBipolar disorderDepression
Respiratory
WheezingCoughCoughing up bloodSevere or frequent coldsDifficulty breathing
Other
Patient Information
Cataract surgery LeftCataract surgery RightGlaucoma surgery LeftGlaucoma surgery RightLASIK surgery LeftLASIK surgery RightRetina surgery LeftRetina surgery Right
Please list all past surgeries:
