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Consider the following questions. This will help your eye care provider understand your needs and medical history.

Reason for Visit​

What is the main reason you're seeing the eye doctor today?
How long has this issue been going on?
Has it been getting better, worse, or staying the same?

Eye History​

Have you seen an eye doctor before (optometrist or ophthalmologist)?
If yes, when and why?

Do you wear glasses or contact lenses?

Have you had any previous eye surgeries or procedures?

Current Eye Medications​

Please list any eye drops or other eye-related medications you currently use:

Family History of Eye Disease​

Does anyone in your family have a history of eye conditions
(e.g., glaucoma, macular degeneration, retinal detachment)?

General Medical History​

Please list any medical conditions you have
(e.g., diabetes, high blood pressure, autoimmune disease, etc.):

Other Medications​

Please list any medications you currently take and their purpose (if known):

Allergies​

Do you have any allergies, including to medications or eye drops?

✅ Thank You!​

Please bring completed answers to your appointment, or send it to the clinic in advance if requested.

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