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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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Other History
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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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Other Ocular History
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Past Ocular Surgeries Right Eye
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Past Ocular Surgeries Left Eye
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Other Ocular Surgeries
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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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Current Medications
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Immunizations
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Past 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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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 Smoke
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I Don't 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 am over the age of 65
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I am over the age of 50
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I am between 45 and 75
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(c)
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