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Name: __________________________________ RoutineVisionQuestionerVisitOnBackofMedicalhistory I am interested in: Eye glasses Contact lenses Colored Contact lenses I would like a copy of my eye glass prescription: Yes or Keep on file. Permission to Dilate: [ ] Yes [ ] No [ ] Will discuss with doctor about dilation & photos. Permission for Retinal Photo ($30.00 recommended every 2 - 3 years): [ ] Yes [ ] No PLEASE CIRCLE ALL THAT APPLY ABOUT YOUR VISION CONCERNING BLUR Unaided (w/out glasses or contacts) w/ spectacles w/ contact lenses DIFFICULTIES OK (None) Possibly Noticeable decline Ongoing problem persists Fluctuation Right eye worse Left eye worse TIMELINE Gradually Recently Suddenly Long-standing Early childhood LOCATION General All ranges Distance Close-range Computer-range Middle-range only Middle / close-range OK distance OK close-range SEVERITY Mild symptoms Troublesome Getting worse Getting better Right eye always poor Always poor AFFECTING Varied Reading Closer than average range Hobby Music Computer-use Intermediate Above eye-level TV captions Distance Driving Night vision Classroom Sports Golf SYMPTOMS Fatigue Headache Squinting Eye strain Words run together Loss of place Reading pushed away Requires more light Sitting close to TV No longer driving CURRENT RX OK Requires updating Better older Rx Better w/o Rx Rx off to read PLEASE CIRCLE ALL THAT APPLY ABOUT YOUR OCULAR SYMPTOMS SYMPTOMS None Asthenopia Eye fatigue Soreness Pain Heavy feeling Pressure feeling Chronic Ocular hemorrhage Foreign body sensation Dry/sandy feeling Redness, some Redness, extreme Burning, some Burning, extreme Itching, some Itching extreme Eyelids puffy Eyelids swollen Eyelids droopy Eye lids baggy Eyelids crusty Watery eyes Lids stick together a.m. Photophobia(Light sensitivity Rubs eyes Mucus-like discharge Filmy-milky discharge Infection Squinting Blinking Twitching Car / motion sickness ONSET Today Yesterday Mornings Evenings As day wears on Recently Increased over time DURATION On occasion One time only Comes and goes Persistent Seasonal Allergy relationship SEVERITY Mild Bothersome Very bothersome Lessening Remaining Increasing CONTEXT No known cause Right more symptoms Left more symptoms Bilateral symptoms Infection relationship Contact Lens relationship Postop relationship Post-trauma relationship Other _____________________________________________________________________________ __________________________________________________________________________________ STAFF ONLY Unaided VA 20 \DVA/ 20 \ / 20 \/ Unaided 20 \NVA/ 20 \ / 20 \/ Presenting SP CL 20 \DVA / 20 \ / 20 \ / Presenting SP CL 20 \NVA / 20 \ / 20 \/ [ ] Diabetes [ ] Diabetic Retinopathy [ ] Hypertension [ ] High Cholesterol [ ] Mac. Deg. [ ] Glaucoma [ ] None [ ] Aetna [ ] BCBS [ ] Cigna [ ] Medicare [ ] UHC [ ] VSP [ ] Eye Med [ ] Spectera [ ] Davis [ ] Private Pay iCare ____/____ Optician Retinal photos: Screening Color Fundus OCT: Optic nerve 200X200 Macula 512X128
