Richmond Eye Associates Patient Information Form


	Richmond Eye Associates -- Patient Information (page 1) Patient's Name: _________________________________ Age: _______ Reason For Visit: Today's Date: ________ ________ Possible medical or surgical eye problem? Last Eye Exam: ______ ________ Routine eye examination? ________ Referred by a physician or optometrist? Referring doctor: ________________ ________ Interested in contact lenses or refractive surgery? Eye Conditions and Symptoms:


	_____ Glaucoma _____ Cataract _____ Retinal Problems _____ Muscle Imbalance _____ Eye Injuries _____ Dry Eye


	_____ Glasses Use _____ Contact Problems _____ Blurred Vision _____ Eye Pain _____ Eye Infection _____ Eye Itching


	_____ Redness _____ Tearing / Discharge _____ Double Vision _____ Floaters / Flashing _____ Eyelid Problems _____ Halos


	Past Medical Problems (check if YOU have had any of these problems):


	_____ Diabetes _____ Weight Change _____ Sinus Infections _____ Heart Disease _____ Shortness of Breath _____ Arthritis / Joint Pain _____ Dizziness _____ Memory Loss _____ Depression _____ Circulation Problem _____ On a Blood Thinner Do You Use Tobacco? _____ Yes _____ No


	_____ High Blood Pressure _____ Fever _____ Ear Nose Throat _____ Allergy / Hay Fever _____ Asthma _____ Gastrointestinal Prob. _____ Rash / Skin Disorder _____ Seizure _____ Stroke / Paralysis _____ Anemia _____ Bleeding Tendency Do You Drink Alcohol? _____ Yes _____ No


	_____ High Cholesterol _____ Headache _____ Thyroid Trouble _____ Bronchitis _____ Urinary Problem _____ Kidney Stones _____ Neurological _____ Cancer _____ Immune Problem _____ HIV Positive? _____ Gout Are You Pregnant? _____ Yes

Family History: Has anyone in your family had the following?


	_____ Glaucoma _____ Diabetes _____ Glasses Use


	_____ Cataracts _____ Macular Degeneration


	_____ Blindness _____ Muscle Imbalance _____ Retinal Problem

Richmond Eye Associates -- Patient Information (page 2)

Patient's Name: _________________________________

Other Medications that You Take:

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Eye Medications that You Use:

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List Any Medication Allergies:

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Please List any Surgical Procedures or Injuries You Have Had:

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If you wear Contact Lenses, complete this section:

Soft Lenses? Y / N Gas Permeable Lenses? Y / N Hard Lenses? Y / N
What Brand of Lenses? __________________________________
How Many Years Have You Worn Contact Lenses? ______
Do You Sleep in Your Contact Lenses? Y / N
What Supplies or Solutions Do You Use? _____________________