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OptimEyes PATIENT HISORY FORM Name ____________________________________________________________________________ Date of Birth ____________________________ Address __________________________________________________ City _____________________ State ____________ Zip ________________ Phone ____________________________________________ Email ___________________________________________________________________ What is the reason for today’s visit? _____________________________________________________________________________________________________ When was the approximate date of your last eye exam? ____________________________________ If the doctor finds it necessary, are you willing to have your eyes dilated today? Do you wear glasses? Yes No Do you wear contacts? Yes No Do they need to be improved? Yes No Are you interested in contacts today? Yes Yes Last dilation? _________________________ No (If no please sign dilation waiver below) How old is current pair? _____________________ No If you wear contacts: What brand? ______________________________ How often replaced? _____________________ What solution used?______________________ Do you use tobacco? Yes No (If yes, how often? _____________________). Are you pregnant and/or nursing? Yes No List any medication you are currently taking (including eye drops and vitamins). ______________________________________________________ ______________________________________________________________________________________________________________________________________________________________ Are you allergic to any medications, if so which? ________________________________________________________________________________________ Do you or any of your blood relatives currently have or have had any of the following conditions? (Circle Y/N, list relative) Diabetes Yes No Relative _________________ Macular Degeneration Yes No Relative _________________ High Blood Pressure Yes No Relative _________________ Lazy Eyes (Amblyopia) Yes No Relative _________________ Thyroid Yes No Relative _________________ Double Vision Yes No Relative _________________ Heart Disease Yes No Relative _________________ Redness/Watery Eyes Yes No Relative _________________ Asthma Yes No Relative _________________ Itching/Burning Yes No Relative _________________ Cancer Yes No Relative _________________ Floaters Yes No Relative _________________ Corneal Disease Yes No Relative _________________ Flashes of light Yes No Relative _________________ Glaucoma Yes No Relative _________________ Gritty/Sandy feeling Yes No Relative _________________ Cataracts Yes No Relative _________________ Aching/Pulling Yes No Relative _________________ Eye Surgery Yes No Relative _________________ Dryness Yes No Relative _________________ Retinal Disease Yes No Relative _________________ Headaches Yes No Relative _________________ Crossed Eyes (Strabismus) Yes No Relative _________________ Eye Injuries/Infections Yes No Relative _________________ By signing below, I acknowledge that the above information is filled out to the best of my ability. Signature______________________________________________________________________ Date ____________________________________________________ DILATION WAIVER (ONLY sign below if you are refusing dilation) I, under my own will and judgement, refuse to have my eyes dilated. As a direct consequence, I understand that the Doctor may not be able to detect cases in which the retina is diseased, physically compromised, or harboring tumorous growths. Accordingly, the process of early detection and diagnosis of certain eye conditions may be hindered, and timely referral to a specialist and effective treatment may not be possible. I accept ANY and ALL risk for this possibility without a pupillary dilation, and I understand that these conditions have the potential to result in permanent blindness, or even death. I understand that this refusal may be against the Doctor’s professional judgement, advice, or recommendation. Signature______________________________________________________________________ Date ____________________________________________________
