REVIEW OF SYSTEMS:
  • 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.)
PAST HISTORY
  • Eye drops currently in use: (list)
Allergies to eye drops
  • History of cataract, glaucoma
  • History of cross/lazy eye
  • Eye injury or other disease
  • Eye surgery
List drops you are allergic to:

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
FAMILY HISTORY
  • YES NO EXPLANATION/RELATIONSHIP
  • OCULAR
  • Blindness
  • Cataract
  • Glaucoma
  • Macular degeneration
  • Retinal detachment
  • MEDICAL
  • Diabetes
  • Arthritis, lupus, etc.
  • Other (list)
SOCIAL HISTORY
  • 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
GENERAL
  • 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?