Ophthalmic evaluation form

Date (DD/MM/YYYY):

Full Name:

Birthday:

Phone Number:

Best time / day to contact:

Email:

Religion

Gender:

Marital Status:

Weight:

Height:

Place of birth:

Residence: (City, Country)

Did you smoke?
YesNo

Amount / Frequency:

Did you drink?
YesNo

Drinks per week:

Did you use any drugs?
YesNo

What / Frequency

Practice any sport?
YesNo

Type / Frequency

Have any allergies?
YesNo

Type:

Allergies to any medicine?
YesNo

Which:

Special diet?
YesNo

Explain:

Do you have or had some type of Cancer in the last 5 years?
YesNo

Type / Date / Treatment:

Reason for consultation:

First Symptom Date:

Diagnostic Date (DD/MM/YYYY):

Eye surgeries in the past: right eye? left eye?:

Initial symptoms:

Current symptoms:

Current medication & eye drops:

Last eye examination date & ophthalmologist name:

Visual acuity right eye (with and without correction):

Visual acuity left eye (with and without correction):

Intra Ocular pressure (right eye and left eye):

Diagnosis (right eye and left eye):

Treatments received on the past:

Other Illness present:

Other medication currently in use:

Non Ophthalmic previous surgeries (please explain cause and date):

Description of current condition and Comments (Autonomy, Special requirements, wheelchair, transport, passengers, physical help, limitations, etc):

How did you find out about ProgenCell?:

Number of pregnancies:

Vaginal births:

C-sections:

Abortions:

Menopause:

Using hormone therapy:

Personal information

Current Illness

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