Patient Medical History
Patient questionnaire
Name:
Surname:
Age:
History:
I am treated for:
- Diabetes – type ……………
- Ischemic heart disease
- Heart attack
- Stroke
- High blood pressure
- Hepatitis
- Rheumatism
- Blood circulation problems
- Prostate hypertrophy
- None of these
I use:
- PAD
- Insulin
- None of these
I am:
- Myopic (shortsighted)
- Hypermetropic (farsighted)
- Presbyopic
My glasses or contact lenses are for far distance:
Right eye: Left eye:
Diopters Diopters
Cylinder Cylinder
Axis Axis
My reading glasses:
Right eye: Left eye:
Diopters Diopters
Cylinder Cylinder
Axis Axis
Note:
I want to:
- Remove the need for glasses/contact lenses
- Remove the cataract/s
- Other
Eye anamnesis:
I have been previously treated for:
- Strabismus
- Amblyopia
- Glaucoma
- Cataract
- Keratoconus
- Herpes
- Eye injury
- None of these
I wear contact lenses:
- Daily lenses
- Weekly lenses
- Monthly lenses
- None
I have already been to a specialized eye doctor
- Yes
- No
I have already undegone eye surgery
- Yes
- No
- Details.