NAME:
DATE :
CHART # :
PLEASE ANSWER THE FOLLOWING QUES TIONS TO THE BEST OF YOUR ABILITY .
OCULAR HISTORY : DO YOU OR HAVE YOU HAD?
CATARACTS
GLAUCOMA
- - - - - - - - - - - - - - --
- - - - - - - - - - - - - - - -
SURGERY
- - -- - - - - - - - - - OTHER
- -- - - - - - - - - -- --
RETINAL DIS EASE
- - - -- - - - - - - MEDI CAL HIS TORY : DO YOU OR HAVE YOU HAD?
DIABETES
- - - - - - - - - - - - - - - -
THYROID PROBLEM
_
HEART ATTACK
- -- - - - - - - - - - - -
CANCER- -- - - - - - - - - - - - -
HIGH BLOOD PRESSURE
ARTHR I TIS -
ASTHMA
- - - - - - - - - - - - - - - - MIGRAINES
_
SKIN PROBLEMS - - - -- - - -- - HIGH CHOLESTEROL
SURGERY- -- - - - - - - - - - - - - - -
OTHER- - - - -- - - - - - - - -- -
- - -- - - - - - -
-
-
-
-
-
-
-
-
-
-
-
-
~
FAMI LY HIS TORY OF EYE DIS EASE
- - - - - - - - - - - - - - - - -- - - - - - - - -
PLEASE LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING:
ARE YOU ALLERG IC TO ANYTHING ( INCLUDING MEDICAT IONS ) ?
PATI ENT S IGNATURE
DATE
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_