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.