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Located inside Waterford Lakes LensCrafters, next to Chase Bank and Starbucks

Located inside Waterford Lakes LensCrafters,
next to Chase Bank and Starbucks

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Eye Exam Paperwork

HOURS & LOCATION
OUR OPTOMETRISTS
- DR. NAILA M. VIRANI
- DR. BRIAN RUNDA
DIGITAL EYE EXAM
EYE CARE SERVICES
CONTACT LENSES & EYEWEAR
EYE EXAM Q&A
EXAM PAPERWORK

HOURS & LOCATION
OUR OPTOMETRISTS
- DR. NAILA M. VIRANI
- DR. BRIAN RUNDA
DIGITAL EYE EXAM
EYE CARE SERVICES
CONTACT LENSES & EYEWEAR
EYE EXAM Q&A
EXAM PAPERWORK

Home » Contact Us » Eye Exam Paperwork: Please fill out the 2 links (you do not need a printer). Both links are required » Dilation Consent and Medical History

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*
MM slash DD slash YYYY
Medical History
Are you Pregnant or Nursing?*
- Yes
- No
Last eye exam*
Are you Diabetic?*
- Yes
- No
Last fasting blood sugar
Date
MM slash DD slash YYYY
HbA1c
Date
MM slash DD slash YYYY
Last visit w/PCP/MD
Average fasting blood sugar
Do you have medication allergies?*
- Yes
- No
List ANY medication allergies:*
Are you currently taking any medications?*
- Yes
- No
List Current Medications:*
List major injuries/surgeries/hospitalzations (if none, please type "none"):*
Any eye surgeries?*
- Yes
- No
List here
Do you wear glasses*
- Yes
- No
Do you wear contacts?*
- Yes
- No
Contacts lens brand
Do you use tobacco products?*
- Yes
- No
type/amount/how long
Do you drink alcohol?*
- Yes
- No
type/amount/how long
Have you been exposed or infected with:
- Gonorrhea
- Hepatitis
- HIV
- Syphilis
- No
Family History
Ocular/Systemic Conditions
Family Member Affected (Maternal/Paternal)
- Blindness due to Disease
Family Member Affected
- Blindness due to Injury
Family Member Affected
- Glaucoma
Family Member Affected
- Macular Degeneration
Family Member Affected
- Retinal Detachment
Family Member Affected
- Retinal Degeneration
Family Member Affected
- Arthritis
Family Member Affected
- Cancer
Family Member Affected
Type:
- Diabetes
Family Member Affected
- Heart Disease
Family Member Affected
- Hypertension
Family Member Affected
- Kidney Disorder
Family Member Affected
- Thyroid Disease
Family Member Affected
- OTHER
Family Member Affected
- NONE OF THE ABOVE
Patient History/Review of Systems
Cardiovascular
- 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 NO
YES NO
Blurry Vision
Double Vision
Eye Fatigue
Loss of side vision
Dryness
Redness
Itching
Burning
Mucous Discharge
Eye Pain
Light Sensitivity
Watery Eyes
Floaters
Flashes
Distorted Vision/Halos
Other
Please note any other medical or ocular conditions not listed
Name
First Last
Birthdate
MM slash DD slash YYYY
Cell phone number
Date
MM slash DD slash YYYY
Signature

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Alafaya Vision Center

Phone: (407) 382-2648
Fax: (407) 382-8785
Email: contactus@yourorlandooptometrist.com
(Do not send personal health information by email.)

891 N Alafaya Trail
Orlando, FL 32828

Monday: 10:00 AM - 6:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 6:00 PM
Saturday: 10:00 AM - 6:00 PM
Sunday: 12:00 PM - 4:00 PM

N. Alafaya Trail

waterford lakes eye doctor

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HOURS & LOCATION
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EXAM PAPERWORK

HOURS & LOCATION
OUR OPTOMETRISTS
DIGITAL EYE EXAM
EYE CARE SERVICES
CONTACT LENSES & EYEWEAR
EYE EXAM Q&A
EXAM PAPERWORK

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Alafaya Vision Center - Located at 891 N Alafaya Trail, Orlando, FL 32828 Phone: 407-382-2648 www.yourorlandooptometrist.com

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