WARWAR EYE GROUP
Ronald E. Warwar, M.D.
Gregory J. Bruchs, O.D.
3100 Governor's Place Blvd.
Kettering, Ohio 45409
(937) 297-7676


COMPREHENSIVE OPHTHALMIC HISTORY FORM

Please complete the information below and submit the form online, or if you prefer, print out the completed form and bring it with you when you come to our office.
 
Patient's Name:   Date: 
Street Address: 
City, State, Zip:
Family Doctor:
Referring Doctor:  
Where did you hear about our office?  

Ophthalmic History

1. Reason for visit:


2. Please check the symptom(s) you have had:

Right
Eye		 Left
Eye		 Both
Eyes
Eye(s) burning, stinging, irritation, dryness, or itching
Discharge or mattering in the eye(s)
Redness in the eye(s) or eyelid(s)
Tearing from the eye(s)
Blurred or foggy vision
Double vision
Floaters, spots or flashes of light
An eyelid or eyeball growth or bump
Swelling of the eyelid(s)
Other: 


3. Please check any of the following eye surgeries or conditions which you have had:

Cataract surgery:
Right eye
Left eye		 Glaucoma
Lazy eye
Macular degeneration
Diabetic retinopathy Strabismus ("cross-eye")
Eye laser surgery Other:


4. Please check any eye conditions in your family members.

Cataracts  Glaucoma
Retinal detachments/disorders Lazy Eye
Optic nerve diseases

 

General Medical History

1. Do you smoke?  Yes   No    If yes, how many packs per day? 

2. Please list your current medications, including eyedrops:

3. Please list any allergies you have to medications or eyedrops: 

4. Please check any other illnesses you have had in the past, or that you currently have.

Diabetes High blood pressure
Cancer
      Where? 		Stroke
Depression
Heart attacks/heart disease Stomach or intestinal disorders
Bronchitis/Emphysema/Asthma Arthritis
Other:

5. List any major surgeries which you have had: 


6. Do your family members or parents have any of these disorders? Please check any that apply.

Diabetes Cancer
Heart diseases Bleeding disorders
Strokes  Lung diseases or breathing problems
High blood pressure


Review of Systems

Please check any of the following symptoms that you have experienced recently:

Dizziness or light-headedness Diarrhea or loose stools
Skin rashes Urinary problems
Unexplained fevers or weight loss Joint or bone problems
Hearing or balance problems Weakness or paralysis
Wheezing, asthma, or bronchitis Shortness of breath
Palpitations or abnormal heart rhythm Chest pain
Swelling in the ankles or feet Nausea or vomiting
Other:

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