Do you have problems with your eyes limiting you in performing any of the following during the last week?
Have your eyes felt uncomfortable in any of the following situations during the last week?
Family Eye History
|Primary Care Physician: ||
||Last Visit: ||
||Over The Counter: ||
|Pregnant or Nursing: ||
||Recent Tetanus Shot: ||
|Injuries, Surgeries, Hospitalizations:|
Review of Systems
|| Ear, Nose, Throat: ||
||Genital, Kidney, Bladder: ||
||Muscles, Bones, Joints: ||
Family Medical History
Please list any medical conditions that may run in your family.
A DIGITAL IMAGE OF THE RETINA WILL BE PERFORMED ANNUALLY FOR EVERY PATIENT!
Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments
and diabetic retinopathy
can now be seen without dilation for most patients and it is far easier
for the doctor to examine the eye with the digital
image instead of looking through the eye with
a microscope which gives a very limited view. The time to evaluate the retina
is instant, the
exam is painless and allows a 200 degree view of the entire internal health of the eye without drops.
Early detection is crucial! Without a thorough eye examination serious disease can be missed
such as: diabetes, retinal
detachments or malignant tumors. All of these can lead to vision loss,
blindness or even death.
The small fee is $39 and may be covered by your health insurance
company, if a medical condition is found.
A DIABETES RISK EVALUATION WILL BE PERFORMED FOR ALL PATIENTS OVER THE AGE OF 18!
As a leading cause of blindness, it is very important for us as your eye doctor to test for this
disease. Early detection
is now available, and it is PAINLESS, QUICK and NON-INVASIVE.
A six second scan of the lens of you eye will show us your
entire lifetime of blood sugar
control and it can tell us up to 7 years before diabetes complications start.
The small fee for the evaluation is $39.
A discounted fee of $69 will apply when both tests are
Please let us know if you have any questions regarding these important ocular evaluations.