- Eyes
- Loss or blurred vision
- Loss of side vision, double vision
- Itching, burning, or discharge
- Redness
- Gritty feeling, dryness or tearing
- Glare/light sensitivity, or halos
- Eye pain or soreness
- Infection of eye lashes or lid, styes
- Ears, nose, mouth, throat
- Cardiovascular, (heart, blood vessels)
- Respiratory (lungs/breathing)
- Gastrointestinal (stomach/intestines)
- Genitourinary (genitals/kidney/bladder)
- Musculoskeletal (muscles/joints)
- Integument (skin/breast)
- Neurological
- Psychiatric
- Endocrine (hormones, glands)
- Hematologic/Immunologic (blood)
- Seasonal allergies (hay fever, etc.)
- Eye drops currently in use: (list)
- History of cataract, glaucoma
- History of cross/lazy eye
- Eye injury or other disease
- Eye surgery
PAST HISTORY (MEDICAL)
- List any medications (other than eyedrops) that you are currently using:
- List all major illnesses: Diabetes _______ Hypertension _______
- Other:
- List any major surgical procedures:
- Do you have any medication allergies? Penicillin Sulfa
- YES NO EXPLANATION/RELATIONSHIP
- OCULAR
- Blindness
- Cataract
- Glaucoma
- Macular degeneration
- Retinal detachment
- MEDICAL
- Diabetes
- Arthritis, lupus, etc.
- Other (list)
- YES NO EXPLANATION
- OCULAR
- Have you ever tried to wear contacts?
- Did you have problems with contacts?
- Vision causes problems with:
- ? Driving ? Night vision ?Reading ? Sports/Outdoor activities
- Do you drink alcohol? How much per day?
- Do you smoke?
- Have you ever had a blood transfusion?
- Have you ever had contact with a person who had a sexually transmitted disease?