1.
Please describe any problem or concern you have with your eyes:____________________________
2.
Do you currently wear ____ glasses ___ contact lenses ___ neither for : ___ reading ___ distance
3.
Date of Most recent eye exam______________________________________________________.
4.
Have you had any eye surgery if so explain___________________________________________
5.
Please check any of the following problems you have with your vision.
____ failing vision
____ double vision
____ blurred vision
_____ poor night/ driving vision
6.
_____ halos around lights
_____ spots before eyes
____ flashes of light
Please check any of the following symptoms you have with your eyes.
___ red eyes
___ mucus in eyes
___ tearing
___ light sensitivity
___ foreign body sensation
7.
____ glare
____ color blindness
____ distorted images
____ itching/burning
___ sandy sensation
___ aching pain
Please check any of the following symptoms with your eyelids.
___ itching/burning
___ dryness/scaling
___ granulation/crusting in am
___ redness/swelling
8.
Have you ever had an eye injury or head injury? ___ yes ___ no
9.
List all drug allergies _____________________________________________________________
10. Please list all medication you are currently taking, including non-prescription medications.
11. Please indicate the following information for your last hospitalizations.
Illness or operation/ reason
Month/year_______________
____________________________
__________________________
12. Please indicate if you have any of the following:
___ Diabetes
___hypertension
___ glaucoma
___ retinal detachment
Past Eye History:_______________________________________________________________________________
Family History:
Disease
Yes
No
Relationship to patient (blood relatives only)
Blindness
___
___
_________________________________
Cataract
___
___
_________________________________
Glaucoma
___
___
_________________________________
Macular Degeneration
___
___
__________________________________
Retinal Detachment
___
___
__________________________________
Arthritis
___
___
___________________________________
Cancer
___
___
___________________________________
Diabetes
___
___
___________________________________
Heart Attack
___
___
____________________________________
High Blood Pressure
___
___
_____________________________________
Lupus
___
___
_____________________________________
Sjogrens Syndrome
___
___
______________________________________
Stroke
___
___
_______________________________________
Thyroid disease
___
___
________________________________________
Do you drive?
___
___
Any Difficulty? ___________________________
Do you smoke?
___
___
How much? ______________________________
Do you drink alcohol?
___
___
How much? _____________________________
Social History:
Marano Eye Care Centers
Privacy Practice Acknowledgement
I have received the notice of Privacy Practices and I have been provided an opportunity
to review it.
Print Name:_______________________________________________________
Signature:________________________________________________________
Date:____________________________________________________________
Authorization to Release/Discuss Health or Insurance Information with a Personal
Representative
Personal
Representative Name:______________________________________________
Relationship to Patient:____________________________________________
Patient Signature: ________________________________________________