The Eye Works – Patient Questionaire – Patient Registration Forms

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The Eye Works – Patient Questionaireadmin2017-09-21T04:29:47+00:00

The Eye Works - Patient Questionaire

Do you experience, or have you had any of the following? With current correction
- Blurry vision - distance or near
- Fluctuating vision
- Eye pain or soreness
- Eyestrain
- Chronic dryness
- Burning eyes
- Eyes tear or water
- Eye discharge
- Scratchy, gritty, sandy feeling
- Floaters/spots
- Flashes of light
- Headaches/Migraines
- Trouble with night vision
- Eye infections recently
- Eye injury/Trauma
- Glare at night
- Sun sensitivity
- Double vision
- Macular degeneration
- Cataracts
- Glaucoma
- Crossed or wandering eye
- Lazy eye
- Iritis/Uveitis
- Retinal detachment/Tear
- Eye surgery
Personal Medical History (Click all that apply)
- High blood pressure
- Cholesterol
- Diabetes
- Thyroid Hi/Low
- Neurological disease
- Arthritis
- Depression/Anxiety
- Lyme disease
- Allergies
- Head trauma
- Kidney disease
- Weight gain/loss
- Ocular herpes
- Cancer - Type
Family History
Diabetes - Who
Glaucoma
Macular degeneration
High blood pressure
Blindness
Stroke
List all current meds
Last med exam
MM slash DD slash YYYY
Physician's name
Additional comments
HIPPA PRIVACY NOTICE: This office's privacy practices are in accord with HIPPA regulations. You may obtain a copy of our privacy practice at any time.Your signature here indicates that you have been advised of the availability of this information.
Signature
Date
MM slash DD slash YYYY

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