Patient Medical Questionnaire

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.