PATIENT QUESTIONNAIRE
Patient Questionnaire
NAME__________________________________ TODAY’S DATE_________________
AGE________________ DATE OF BIRTH________________
OCCUPATION_________________________ RETIRED? _____________________
REASON FOR VISIT___________________________
PRIMARY CARE DOCTOR__________________________Who referred you today:______________
Do you currently have any of the following? Do you have any of the following today?
YES NO YES NO
Reduced vision w/glasses ______ ______ Cold sores/Blisters ______ ______
Double Vision ______ ______ Dry mouth ______ ______
Eye pain ______ ______ Headache ______ ______
Eye redness ______ ______ Chest pain ______ ______
Eye discharge ______ ______ Allergies ______ ______
Eye itching ______ ______ Trouble breathing ______ ______
Eye burning ______ ______ Pregnant ______ ______
Eye watering ______ ______
Glare ______ ______
Light sensitivity ______ ______
Floating spot(s) ______ ______
Flashes of light ______ ______
Do you wear any of the following (Circle One)? GLASSES CONTACT LENSES BOTH
|Have you ever been told you have any of the following? |
| |YES |NO |EXPLAIN |
|Near-sighted (myopia) glasses for distance | | | |
|Far-sighted (hyperopia) | | | |
|Glasses for reading | | | |
|Astigmatism | | | |
|Cataracts | | | |
|Keratoconus | | | |
|Glaucoma | | | |
|Macular degeneration | | | |
|Dry eyes | | | |
|Do any of your blood relatives have: |
|Glaucoma | | | |
|Macular degeneration | | | |
|Other eye disease | | | |
Have you ever had any type of eye surgery such as (Cataract Surgery, LASIK or Laser Vision Correction) or any other eye disease?
-----------------------
Eye Drops Used: ________________
_____________________________________________________________________________________________
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