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Date: Reviewed by: MEDICAL HISTORY QUESTIONNAIRE OPHTHALMOLOGY Name: Date of Birth: / / Ethnicity: Primary Care Physician: Referring Doctor: Referring Optometrist: Pharmacy: Location: Pharmacy phone.

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HISTORY Visual Complaints. As one patient taught me, there are usually no visual complaints in glaucoma. ... Ocular Symptoms. ... Past Ocular History. ... Past Medical History. ... Current Topical Medications and Prior Medication History. ... Family History. ... Allergies to Medications. ... Systemic Medications.

For each complaint, ask about: Onset (sudden or gradual) Course (how it has progressed) Duration (how long) Severity. Location (involving one or both eyes) Any relevant associated symptoms. Any similar problems in the past. Previous medical advice and any current medication.

Ocular history should inquire about past clinic visits and surgeries. Specifically inquire about cataract surgeries, eye trauma, and glaucoma. You can often piece together your patient's ocular history by examining their eyedrops.

Ocular history should inquire about past clinic visits and surgeries. Specifically inquire about cataract surgeries, eye trauma, and glaucoma. You can often piece together your patient's ocular history by examining their eyedrops.

Questions to ask for the HPI: Are both eyes or one eye affected? - Which parts of the visual field are affected in each eye? Is there pain? Is there redness? Was there recent trauma?

Common Questions Patients Ask About Their Eyes Will wearing reading glasses make my eyes worse? “This is a very common question. ... Do I have to wait to have cataract surgery until my cataracts are “ripe”? ... Does using marijuana help treat glaucoma? ... Will fish oil help my eyes? ... Can I drive if my eyes are dilated?

The key characteristics: Sudden increase in the pressure within one eye which becomes red and painful. Usually unilateral presentation. Acute or chronic history such as occasional glare and haloes around lights, especially at night when pupils are dilated.

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© Copyright 1997-2025
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3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232