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Major purpose of this visit: Routine Eye Exam Contact Lens Exam Medical Visit Date of Last Eye Exam: Practice: Doctor: Are you currently a contact lens wearer? Yes / No Do you currently wear glasses? Yes / No Are you a previous contact lens wearer? Yes / No Current prescription: Distance Computer Contact lens brand: Reading Multifocal Solution brand: Have you ever experienced, been diagnosed Are you having any of the following? or treated for any of the following? A.) Symptoms: B.) Vision Concerns: NONE NONE NONE Cataract RednessBlurred vision Macular Degeneration BurningEyestrain Glaucoma ItchingEye pain Diabetic Retinopathy TearingSevere sensitivity to lights Dry Eye Discharge Headache Eye infection, inflammation, or allergyPoor night vision Floater, and/or flashes of lightBothersome night glare Iritis or UveitisDouble vision Retina defects or DegenerationTotal loss of visionDate of Last Physical Check-up: Practice: Doctor: CURRENT MEDICATIONS List name of ALL medications including eye drops, vitamins, & birth control pills etc. (Prescription or OTC):Allergies to any medications? Yes No If yes, what medications?Have you had any surgeries? Yes No If yes, what and date?Do you use cigarettes/ tobacco, alcohol, or other substances? Yes NoHave you ever been diagnosed or treated for the following health problems?Allergies (Seasonal/year round) Yes NoFevers Yes NoArthritis Yes NoUnusual Weight loss/ gains Yes NoBlood/ Lymph Yes NoHigh Blood Pressure Yes NoBronchitis Yes NoIntegumentary (Skin) Yes NoCancer Yes NoKidney Yes NoCholesterol Yes NoMuscle/ Bone Yes NoDiabetes (Type____, Last A1C____) Yes NoNeurological Yes NoDigestive Yes NoPsychological Yes NoEars/Nose/Throat Yes NoRespiratory Yes NoEndocrine Yes NoSinus Yes NoEczema/ Rashes Yes NoThroat Infections Yes NoFatigue Yes NoThyroid Yes NoIs there a family medical history of any of the following?Immediate family members (example: Father; Mother; Son; Daughter; Sister; Brother; Grandmother; Grandfather)Cancer Cataracts Diabetes type: ____ Glaucoma Hyperthyroidism Macular Degeneration Hypertension Retinal Problems Heart DiseaseDilationDuring a traditional eye exam, the Doctor dilates your eyes with special eye drops and then checks your retinas for abnormalities. The eye drops used for dilation cause your pupils to widen, allowing in more light and giving your doctor a better view of the back of your eye. Eye dilation assists the Doctor in diagnosing common diseases and is especially important if you're at high risk of retinal conditions. Eye dilation will make your vision blurry, and your eyes will be sensitive to light up to three to four hours. This can affect your ability to drive or work after. We will be happy to provide you with disposable sunglasses after your appointment.OptomapDuring a laser retina scan, such as Optomap, quick and painless images are taken of your eyes. These images can be studied to check for abnormalities and saved in your medical record to compare the condition of your retinas from year to year. The retina scan is not necessarily a substitute for dilation, but to enhance your overall comprehensive eye exam. An eye exam including the Optomap screening is very beneficial in helping you and your Doctor maintain your health eyes, inside and out.Are you prepared to be dilated today? Yes, I am prepared to have my pupils dilated today, and understand the side effects. I would prefer to reschedule for dilation. I do understand there will be an additional fee for rescheduling at a later time and day. No, I decline under my own will and judgment. I fully understand the circumstances associated with refusing to have my eyes dilated. I understand that the doctor may not be able to detect cases in which the retina is diseased, physically compromised, or harboring cancerous growths. As such, early detection and diagnosis of certain eye conditions, along with timely and effective treatment, may not be possible. I accept all risk for the possibility of not detecting these eye conditions without dilation, and I understand that these conditions may result in permanent blindness, or even death. Name: Signature: Date: Would you like to have the Optomap screening done today? Yes, I would like the Optomap? performed today. I have reviewed the information given and agree to the terms and additional fee. Unsure, please tell me more. No, I decline under my own will and judgment. I fully understand this screening, which captures a wider range of the retina, is put in place to enhance the traditional procedure of dilation. This will overall improve the doctor’s ability to examine the health of my eyes. I accept all risk for the possibility of not detecting these eye conditions without dilation, and I understand that these conditions may result in permanent blindness, or even death.Name: Signature: Date: -12980653517Were you referred?Family/Friend – if so who may we thank for referring you to our office? Name of friend or relative:Another Office – if so who may we thank for referring you to our office?Name of Office/DoctorInsurance or advertisement listing. ................
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