Dilation Consent and Medical History Form 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 HistoryAre 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 HistoryOcular/Systemic ConditionsFamily 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 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/HalosOther Please note any other medical or ocular conditions not listed Name First Last Birthdate MM slash DD slash YYYY Cell phone numberDate MM slash DD slash YYYY Signature
