Risk Management
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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:
- Do you wear glasses? c YES c NO
- Do you wear contact lenses? c YES c NO
- Do you have problems reading? c YES c NO
- 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
- Have you ever had an eye injury? Please describe:
- Have you ever had eye surgery? Please list type, which eye and approximate dates:
R/L
R/L
- Are you currently using any eye medications? Please list name and how often used:
- Are you being treated for any medical conditions? Please circle all that apply:
Diabetes Heart Disease High Blood Pressure
Stroke Arthritis Other:
- What medications other than above are you taking? Please list:
- Are you allergic to any medications? Please list:
- Do you have any family history of eye problems? Please circle and list family relationship:
Glaucoma Cataract Retinal Disease Macular Degeneration
- 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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