Name: _____________________________________________________________________ Date: ___________________________
Address: ___________________________________________________________________________________________________
City: __________________________________________________________ State: ______________ Zip: ____________________
Home Phone No.: ____________________ Work Phone No.: _______________________Other (cell): ______________________
Emergency name/number: _______________________________Home Email Address: __________________________________
Age: ______ DOB: _______________ Sex: ____________ Occupation: _______________________________________________
Employer: _________________________________________________________________________________________________
Routine Optometrist/Ophthalmologist: _____________________________ Family Physician ____________________________
Medical Insurance: __________________________________________________________________________________________

Do you wear Glasses?
Yes (Distance Near Both) No Contact Lenses? Hard Soft GP Last Worn? _______________

How did you hear about us? ___________________________________________________________________________________
Newspaper (note which)________________________________ Patient referral (name)____________________________________
Direct mail/flyer (note which)____________________________ Health Fair/Seminar (note which)___________________________

If you are a good candidate for Vision Correction, how soon would you like to have the procedure? __________________

What has motivated you to consider Vision Correction? (Circle those that apply)
Improvement of job performance
Fire/Rescue Law Enforcement Medical Other_____________________________________________________
Increased enjoyment of sports
Water Sports Skiing Jogging/Hiking Exercise/Aerobics Racquet Sports Golf Other _____________________________________________ The least I expect from Vision Correction is: (Circle all that apply)
Meet job qualifications, which are: ___________________________________________ Do you have any other objectives or expectations from having the procedure? _________________________________________

Do you have any challenges with your night vision while wearing your glasses or contacts?

Have you or do you intend to visit any other Laser Eye Centers or Doctors? YES NO
If yes, which: _______________________________________________________________________________________________

(Turn Over)
Please check YES or NO if you have any of the following conditions:


Pregnant/Nursing or planning on becoming pregnant in next 3 months
Rheumatoid Arthritis
Psychiatric/Psychological Therapy/Depression
Drug Allergies
If yes, to what?_________________________________________________
Have you ever taken Amiodarone (Cordarone, Pacerone)?

Have you taken Acutane (oral acne medication) within the last year?
If yes, when did you stop taking it? ___________________________________________________________________________
Any other Existing Medical Problems:_________________________________________________________________________
List Medications you are currently taking: _____________________________________________________________________

Please check YES or NO if you have any of the following conditions:

Past or present problems with contacts

Ocular Infections? (Specifically Ocular Herpes)
Previous Eye Surgery
History of eye trauma
History of Kerataconus (Chronic Progressive Thinning of the Cornea)
Retina Problems
Eye Muscle Problems or history or eye muscle surgery
Corneal erosion syndrome (from a prior corneal abrasion)
Have you been told you are not a candidate for Laser Eye Surgery
Has your prescription changed significantly in the last year?
Are you over 40 years of age?
Have you had good vision all your life, until age 40?
Do you dislike wearing or dealing with glasses?
Do you remove your glasses to read?

Please check off any symptoms you have experienced with or without contact lenses.
____ Dry sensation

____ Scratchy, gritty feeling
____ Burning
____ Stinging
____ Lid infections
____ Soreness
____ Mucous discharge
____ Irritation from wind or smoke
____ Itching
____ Solution sensitivity
____ Tired eyes
____ Light sensitivity
____ Excessive tearing
____ Lens discomfort
____ Eyelids stuck in a.m.


Enhets nr

Ärendeansvarig _________________________________________________________ Patientens personnr _________________ Namn _______________________________ Informationsdatum Vid det datum som anges ska övriga uppgifter som registreras varit gällande: __________________________ (ÅÅÅÅ-MM-DD) Ange aktuell puls. Vilopuls bör mätas efter två minuters vila och på aktuell enhet.

Collaborazione scientifica e tecnologica tra Cipro e Italia: bando per la raccolta di progetti di mobilità e per la segnalazione preliminare di iniziative rilevanti. stato pubblicato il "Bando per la raccolta di progetti di mobilità nell'ambito del Programma Esecutivo dicollaborazione scientifica e tecnologica tra ITALIA e CIPRO (2007-2009)". Beneficiari

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