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Welcome to RetinaOC
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Right Eye Problems
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Left Eye Problems
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How would you describe your issue?
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How bad are your symptoms?
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When did your problems start?
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How did it start?
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What made it worse?
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What made it better?
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Any other problems at the same time?
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When do you have difficulty?
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I'm interested in laser floater treatment
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Visual Functioning
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Do you have difficulty with the following activities?
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Which eye bothers you?
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Reading
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Doing fine handiwork
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Sports
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Playing games
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Driving and seeing traffic signs
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Watching television
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Navigating steps, stairs, curbs
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Symptoms
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Have you been bothered by:
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Seeing persistent floaters
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Seeing floating "spider webs"
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Blurred/hazy vision
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Double vision
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Eye pain
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Flashes of light
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Glare
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Poor color vision
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Poor night vision
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Poor vision in low or dim light
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Curtain like vision loss
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Sudden change in vision
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Unusual or painful sensitivity to light
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Do you feel that the problem is bad enough to consider laser surgery now?
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Medical History
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Past Ocular History - Right Eye
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Past Ocular History Left Eye
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Past Ocular Surgeries Right Eye
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Past Ocular Surgeries Left Eye
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Past Medical History
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Other Medical History
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Past Surgical History
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Other Surgeries?
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Overall Eye History
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Childhood illnesses
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I have Diabetes
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Year First Diagnosed w/ Diabetes
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Last Sugar Test (Number)
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Hemoglobin A1c?
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Home Sugar Testing?
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Other Doctors
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Ophthalmologist
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Other Ophthalmologist
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Optometrist
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Other Optometrist
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Primary Care Doctor
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Other Primary Care Doctor
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Endocrinologist
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Referring Doctor?
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Immunizations
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Childhood Immunizations
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I got the pneumonia vaccine
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I didn't get the pneumonia vaccine
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I got a flu shot this year
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I didn't get a flu shot
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I am allergic to the flu shot
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I just didn't get the flu shot
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Family History
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Non-contributory?
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Eye Family History
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Family Medical History
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Social History
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Living Arrangements
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Marital Status
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Regular Activities/Hobbies
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Do you drink caffeine?
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I Drink Alcohol
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I Don't Drink Alcohol
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I drink more than 7 drinks a week or 3 per occasion
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I am over the age of 65 or female
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I am male and younger than 65
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I drink more than 14 drinks a week or 4 per occasion
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I Smoke
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I Don't Smoke
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Smoking Details
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Did You Ever Smoke?
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If you smoked before, when did you quit?
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Screening
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I am a woman
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I am a man
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I have urinary incontinence
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I am over the age of 50
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I have been screened for breast cancer
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I've had a mammogram in the last two years
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I've had a bilateral mastectomy
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I am over the age of 50
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I am over the age of 65
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I have been screened for colon cancer
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Colon cancer screening test
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Over the last 2 weeks, how often have you been bothered by any of the following problems?
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Little interest or pleasure in doing things?
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Feeling down, depressed, or hopeless?
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Trouble falling or staying asleep, or sleeping too much?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about yourself?
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Trouble concentrating on things
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Moving or speaking slowly? Or fidgety or restless
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Thoughts of death or suicide?
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Difficulty from these problems: work, home, others
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Review of Systems
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General Problems
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No General Problems
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Skin Problems
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No Skin Problems
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Head/Eye/Ear/Nose/Throat Problems
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No Head/Ear/Nose/Throat problems
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Neck Problems
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No Neck Problems
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Breast Problems
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No Breast Problems
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Heart Problems
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No Heart Problems
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Lung Problems
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No Lung Problems
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Stomach Problems
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No Stomach Problems
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Male Genital Problems
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No Male Genital Problems
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Female Genital Problems
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No Female Genital Problems
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Blood Flow Problems
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No Blood Flow Problems
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Joint/Muscle Problems
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No Joint/Muscle Problems
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Neurologic Problems
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No Neurologic Problems
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Hormonal Problems
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No Hormonal Problems
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Psychiatric Problems
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No Psychiatric Problems
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