Central Arkansas Ophthalmology – Central Arkansas ...



Name: Age: Date:Have you had a history of:YesNoYesNoDouble visionDiabetesDecreased or blurred vision spellsHigh blood pressureEye painHeart diseaseFloaters in your visionLung diseaseFlashing lightsNeurologic disease/strokeEye injuryThyroid diseaseSerious eye infectionEar, nose, mouth, throat problemsEyelid problemsAbnormal pupilEye Surgery (list)Cornea diseaseGlaucomaCataractOther surgery (list)Retinal disorderEye tumorIn or out turning of eyeIs there a family history of: CataractsAllergies to eye drops (list) Glaucoma Diabetes Macular DegenerationAllergies to medications (list) Blindness (any cause) Lazy Eye Other eye disorders CancerAre you experiencing fever/weight loss? HBPWhat is (was, if retired) your occupation?YesNoDo you smoke now?Have you smoked for 1 year or more?Do you drink alcohol daily?Have you had a flu shot vaccination in the last year?Are you concerned that you occupation adversely affects your eyes?Are you HIV Positive?Do you drive?Do you have problems with night vision?Comments (Regarding YES Answers)History Review: No Changes Additions as NotedPatient’s Signature: _________________________________________________ Date: ___________________ ................
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