Eye Center
Patient Name
*
First Name
Middle Name
Last Name
Birthdate
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Male
Female
Age
LAST DATE OF EYE EXAMINATION
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit 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
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