Eye Care History Form - ILLINOIS OCULOPLASTIC ASSOCIATES, S.C.

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Eye Care History

* Indicates required field

Name *

First

Last

DOB *

Name of your eye doctor *

Date of Last Eye Exam *

Do you wear glasses: *

All the time Occasionally Reading Driving TV/ Computer Never

EYE SURGERY: Please indicate if you had any of the following: *

Eyelid Facelift Botox Cataract Glaucoma Retina Other

Primary Care Physician Name *

First

Last

Date of Last Visit *

Do you were contacts: *

Yes No

If yes, indicate Type and Hours/day: *

Please indicate if you have had any of the following: *

Floaters and spots Glaucoma Headaches Itching Eyes Lazy Eye NIght Vision, Poor Light Sensitive Migraine Headaches Seeing Halos Seeing Flashes Retinal Disease Blurred Vision- Distance Blurred Vision- Near Bloodshot Eyes Burning Eyes Cataracts Crossed Eyes Color Vision, Poor Dizzy Spells Double Vision Droopy Eyelids

General Health History

Allergies

Please indicate if you have had any of the following: *

AIDS/HIV Arthritis Artificial Heart Valve Artificial Joints Bleeding Asthma Diabetes Cancer Chemical Dependency Emphysema High Blood Pressure Heart Condition Hepatitis Kidney Disease Lupus

List your allergies to medicines or other substances: *

Medications

List medications you are currently taking: *

List any Eye Drops currently taking: *

Submit

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708-444-7200

708-444-7233

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