Dilation Consent and Medical History Please note: all fields are required to be completed before the form will submit.INFORMED CONSENT OR REFUSAL FOR A DILATED FUNDUS EXAM A dilated exam is a complete exam that helps the doctor detect cataracts, glaucoma, retinal disease, detachments, malignancies and much more, all of which can lead to permanent vision loss. Side effects of dilation typical lasts 4-6 hours, including blurry vision close up and distance. Other side effects include light sensitivity and mild burning upon instillation of drops. In RARE cases induced ocular hypertension with redness, sharp pain, blurry vision and nausea can occur. If this happens seek immediate medical attention. .PLEASE SELECT AN OPTION AND SIGN BELOW* Yes, I have read the above and consent to the dilation procedure. I refuse the dilation procedure and understand the risks associated with not dilating my eyes today. Sign*Date* Date Format: MM slash DD slash YYYY Medical HistoryAre you Pregnant or Nursing?*YesNoLast eye exam*Are you Diabetic?*YesNoLast fasting blood sugarDate Date Format: MM slash DD slash YYYY HbA1cDate Date Format: MM slash DD slash YYYY Last visit w/PCP/MDAverage fasting blood sugarDo you have medication allergies?*YesNoList ANY medication allergies:*Are you currently taking any medications?*YesNoList Current Medications:*List major injuries/surgeries/hospitalzations (if none, please type "none"):*Any eye surgeries?*YesNoList hereDo you wear glasses*YesNoDo you wear contacts?*YesNoContacts lens brandDo you use tobacco products?*YesNotype/amount/how longDo you drink alcohol?*YesNotype/amount/how longHave you been exposed or infected with: Gonorrhea Hepatitis HIV Syphilis No Family HistoryOcular/Systemic ConditionsFamily Member Affected (Maternal/Paternal) Blindness due to Disease Blindness due to Injury Glaucoma Macular Degeneration Retinal Detachment Retinal Degeneration Arthritis Cancer Type: Diabetes Heart Disease Hypertension Kidney Disorder Thyroid Disease OTHER NONE OF THE ABOVE Patient History/Review of SystemsCardiovascular Heart Disease Elevated Cholesterol High Blood Pressure Hematologic Anemia Coagulation Disorder Leukemia Musculoskeletal Arthritis Muscle Pain Joint Pain Rheumatoid arthritis Integumentary (Skin) Lupus Psoriasis Eczema Gastrointestinal Diarrhea Constipation Respiratory Asthma Bronchitis Emphysema Endocrine Diabetes Thyroid Dysfunction Psychiatric ADD/ADHD Anxiety Depression Constitutional Fever Weight Gain Weight Loss Genitourinary Kidney Problems Bladder Problems Ears/Nose/ Throat Chronic Cough Dry Mouth General Allergies Head Colds Eyes Crossed Eyes Lazy Eye Glaucoma Retinal Disease Retinal Detachment Cataract Other Neurologic Headaches Migraines Seizures Multiple Sclerosis NONE OF THE ABOVE OCULAR HISTORY-CHECK YES OR NOYESNOBlurry VisionDouble VisionEye FatigueLoss of side visionDrynessRednessItchingBurningMucous DischargeEye PainLight SensitivityWatery EyesFloatersFlashesDistorted Vision/HalosOtherPlease note any other medical or ocular conditions not listedName First Last Birthdate Date Format: MM slash DD slash YYYY Cell phone numberDate Date Format: MM slash DD slash YYYY Signature