Risk Management



Eye History Form

EYE HISTORY

Name:                                                                                                                      Date:                                                                   

Thank you for choosing our office for your eyecare.  To better serve you, please answer the following questions:

  1. Do you wear glasses?                                  c   YES c   NO
  2. Do you wear contact lenses?                     c   YES c   NO
  3. Do you have problems reading?               c   YES c   NO
  4. Are you currently experiencing any eye symptoms?  Please circle all that apply:

Eye pain                        Blurred Vision                      Eyelid Crusting                     Flashes of Light                   Halos

Discharge                      Light Sensitivity                   Double Vision                       Decreased Vision                 Floaters

  1. Have you ever had an eye injury?  Please describe:                                                                                                                                                                                                                                                                                                                   
  2. Have you ever had eye surgery?  Please list type, which eye and approximate dates:

                                                                                           R/L                                                                                     

                                                                                           R/L                                                                                     

  1. Are you currently using any eye medications?  Please list name and how often used:                                                                                                                                                                                                                                                                        
  2. Are you being treated for any medical conditions?  Please circle all that apply:

Diabetes                        Heart Disease                       High Blood Pressure

Stroke                            Arthritis                                  Other:                                                                                    

  1. What medications other than above are you taking?  Please list:                                                                                                                                                                                                                                                                                            
  2. Are you allergic to any medications? Please list:                                                                                                                                                                                                                                                                                                                          
  3. Do you have any family history of eye problems?  Please circle and list family relationship:

Glaucoma                     Cataract                                Retinal Disease                    Macular Degeneration

  1. Please circle any of the following that you would like more information about:

Radial Keratotomy                     Contact Lenses                    Cataract Surgery

Diabetic Eye Disease                  Glaucoma                             Other:                                                                                    

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