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Please check the description which describes your situation.
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New Patient or New Problem
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Follow up for established problem
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Please select whether you are a new patient or are an established patient with a new problem.
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New Patient
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New Problem
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Please select the option that best describes the reason for your appointment.
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Cataract evaluation
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Decreased vision but unsure why
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Scar tissue on cataract surgery lens
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Another problem
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What is concerning you?
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Which eyes are affected?
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How long has this been bothering you?
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What symptoms are bothering you?
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If other symptoms are bothering you, please list.
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How badly is this bothering you?
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How frequently is this bothering you?
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Check situations where your symptoms are worse.
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If there is another situation in which you are very bothered by your vision, please list it.
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Previous Treatment
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Please share any other comments on your condition.
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Please select any that apply to you.
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Diabetic?
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How long have you been diabetic?
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What do you use to treat diabetes?
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What was your last hemoglobin A1c?
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Ever used prostate medication? (i.e. med ends in -osin)
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What prostate medication(s)?
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Using blood thinners?
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Which blood thinners?
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History of long-term steroid use?
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Please describe steroid use.
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History of significant eye trauma?
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Please describe the trauma.
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Allergy to latex?
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What is your reaction?
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Allery to betadine (povidone-iodine)?
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What is your reaction?
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Have any eye conditions (i.e. glaucoma, macular degeneration)?
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Please list. (If multiple, separate with commas.)
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Use any eye drops regularly (OTC or Rx)?
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Please list drops. (If multiple, separate with commas.)
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Had any prior eye surgeries (including LASIK)?
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Please list. (If multiple, separate with commas.)
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Currently wear contact lenses?
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What type of contact lens?
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Do monovision with contacts?
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Which eye is your distance eye?
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Please remember to not wear contact lenses to your appointment!
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Past Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Primary Care Doctor
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PCP Contact Information
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Family History
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Mother's Medical History
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Comments
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Father's Medical History
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Comments
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Siblings' Medical History
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Comments
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Social History
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Marital Status
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Alcohol
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Smoking Status
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Please list any person(s) you would like for our office to be allowed to disclose your health information.
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Authorized Person for Disclosure #1
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Relationship
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Authorized Person for Disclosure #2
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Relationship
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Authorized Person for Disclosure #3
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Relationship
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