Eye Center
Patient Name*
First Name Middle Name Last Name
Birthdate*
Month Day Year
Date
Sex
Male Female
Age
LAST DATE OF EYE EXAMINATION*
Month Day Year
Date
NAME OF DOCTOR AT LAST EYE EXAMINATION*
LOCATION OF LAST EYE EXAMINATION*
WERE YOUR EYE/S DILATED?*
Yes No I don't know
ARE YOU AWARE OF THE RESULTS?*
Yes No I don't know
WHAT IS THE RECOMMENDED FOLLOW-UP?
weeks/Months/Year
HAVE YOU UNDERGONE OCULAR SURGERY?*
Yes No
*
Cataract Glaucoma Retina Refractive Surgery Extraocular (Plastic/Motility) Others
(please specify details below)*
OCULAR SURGERY DETAILS*
ARE YOU DIABETIC?*
Yes No
WHAT TYPE OF DIABETES DO YOU HAVE?*
Type1 Type2 UNSPECIFIED
DIABETES DURATION*
years
HbA1C (%)
Date
Month Day Year
Date
DO YOU HAVE HYPERTENSION?*
Yes No I Don’t Know
SYSTOLIC BP (mmHg)
DIASTOLIC BP (mmHg)
DO YOU HAVE DYSLIPIDEMIA?*
Yes No I Don't Know
DO YOU HAVE RENAL DISEASE?*
Yes No I Don't Know
ARE YOU PREGNANT:*
Yes No
PREGNANCY DURATION*
Weeks/Months
MEDICATIONS
OTHER SYSTEMATIC CONDITIONS
Should be Empty: