Verdier eye center

Refractive Surgery Evaluation
Patient Information Form
PATIENT INFORMATION:
Name: _________________________________________ DOB: ________ Age:_______ Address: ________________________________________________________________ Email: __________________________________________________________________ Employer: _______________________________________________________________ Emergency Contact: _______________________________________________________ Primary Optometrist: ______________________________________________________ Family Doctor: ___________________________________________________________Address ________________________________________________________________ Referred By: _____________________________________________________________ MEDICAL HISTORY:
Please circle all that apply to you (current or past medical conditions):
Other: _________________________________________________________________
Medications: _____________________________________________________________ List all, including vitamins or herbal preparations Allergies to medications: (Please list) ________________________________________ Do you take any of the following medications? (Please Circle) None Accutane Norplant contraceptive implant Imitrex Amiodarone (cordarone, pacerone) Previous eye surgery or eye problems: ________________________________________ Have you ever been told you have cataracts?___________________________________ Have you ever had cataract surgery?__________________________________________ Do you have any family history of eye disease? ________________________________
Do you have any family history of any of the following (circle all that apply):
Do you see an Optometrist or Ophthalmologist on a regular basis? Who?_____________________________________________________________ When was your last eye examination/ with whom? _______________________________ Has your glasses/contact lens prescription changed in the last 2 years? Do you wear a bifocal in your glasses for reading? Have you ever had double vision in the past? Have you ever been prescribed prisms to wear in your glasses? Are you currently experiencing any of these symptoms with your glasses or contacts or do
you have difficultly with any of these tasks?
Check all that apply to you
____Blurred/fuzzy vision
CONTACT LENS HISTORY:
When was the last time you used your contact lenses? __________________________________ If you wore contact lenses in the past, why did you stop? ________________________________
LIFESTYLE:
Occupation:____________________________________________________________________ Activities/Sports/Hobbies: ________________________________________________________ ______________________________________________________________________________ What do you expect from refractive surgery?__________________________________________ ______________________________________________________________________________ For how long have you been considering refractive surgery? _____________________________ How did you hear about us?
____ I am a patient in the practice
____ Friend who has had refractive surgery If friend or doctor, please tell us who: _______________________________________________ For technician and doctor comments below:
Comments:
_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Source: http://verdiereyecenter.com/documents/verdiereyecenter/Refractive_patient_informed.pdf