Cataract & Family Eye Care
Date:_____________
Name: Mr./Mrs./Ms./Dr.______________________________________________________________________
Last
First
MI
DOB: ______/_______/__________SSN: _________-_______-______________Gender: M F
If child, parent or guardian:______________________________________________________
Race: __________________ Ethnicity: ___________________ Language: ______________
Address:_____________________________________________________ Apt: ____________
City:____________________________ State: _________________ Zip: _________________
Phone: Home (______)______-__________
Cell or work (______)______-_________
Email:________________________________________________________________________
Preferred method of contact: Mail
Home Phone
Cell Phone
Email
Family Doctor: _________________________________________________________________
Address: _____________________________________________________________________
City:____________________________ State: _________________ Zip: _________________
Phone: (______)______-__________
Fax: (______)______-____________
Pharmacy: ______________________________________ Phone:(______)______-__________
1. Have you been treated for any eye problems in the past?
Yes
No
If yes, please specify:
Date
Surgery (including lasers)
Cataract
_____________________________________________________
Glaucoma
_____________________________________________________
Diabetic eye disease
_____________________________________________________
Macular Degeneration
_____________________________________________________
Other (_____________)
_____________________________________________________
Other (_____________)
_____________________________________________________
Do you wear glasses and/or contacts to read?
Y
N
…to watch TV or drive?
Y
N
2. Please circle below if you have ever had any of the following medical conditions:
Date of Diagnosis, if known
Headaches, migraine, or stroke
_________________________________________
High blood pressure, high cholesterol
_________________________________________
Diabetes, thyroid problems
_________________________________________
Heart attack, abnormal heart rhythm
_________________________________________
Emphysema, asthma
_________________________________________
Cancer
_________________________________________
Anemia
_________________________________________
Stomach or bowel disease
_________________________________________
Kidney, urinary or prostate disorder
_________________________________________
Arthritis
_________________________________________
Lupus or autoimmune disease
_________________________________________
Rash or skin disorder
_________________________________________
Seasonal allergies, hay fever
_________________________________________
Other
_________________________________________
3. Have you ever had any surgery? If so, please list:
Surgical Procedure
Date of Surgery
______________________________________________________________________________
______________________________________________________________________________
Name: _______________________________________________________________________
4. Please list your medications (including pills, injections, inhalers, aspirin, vitamins, etc.):
Name of medication
Dose
How many times a day?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Do you use any eye drops?
Name of Drop
Right Eye
Left Eye
How many times a day?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Are you allergic to any medications?
Yes
Medication
Reaction (rash, tongue swelling, etc.)
No
If yes…
_____________________________________________________________________________
_____________________________________________________________________________
Are you allergic to latex? Iodine? Shellfish? Other: ________________________________
7. What is your occupation? _______________________ Hobbies? ____________________
Marital status:
Single
Married
Divorced
Widowed
How much do you smoke? ______________________________________________________
How much alcohol do you drink? _________________________________________________
8. Do any of the following run in your family?
Condition
Relationship to patient
Cataract
Y
N
_________________________________________
Glaucoma
Y
N
_________________________________________
Macular Degeneration
Y
N
_________________________________________
Lazy Eye
Y
N
_________________________________________
Retinal Detachment
Y
N
_________________________________________
Stroke
Y
N
_________________________________________
Diabetes
Y
N
_________________________________________
Thyroid disease
Y
N
_________________________________________
10. Are you currently experiencing any of the following symptoms?
Blurry vision
Distorted vision
Glare or halos
Flashes or floaters
Double vision
Eyes feel dry/scratchy
Discharge from eyes
Itching or burning eyes
Pain in sunlight
Eye strain
Fever
Weight loss or gain
Headaches
Hearing loss
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Sinus congestion
Hay fever
Cough, wheezing
Chest pain
Swelling in feet
Shortness of breath
Abdominal pain
Diarrhea or constipation
Frequent urination
Joint pain or swelling
Decreased energy
Rash or dry skin
Dizziness
Numbness or weakness
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N