Name

Date of Birth

Filled out by

Date of Information

Reason for examination

Changes in Vision

Glasses or Contact Lenses

Previous eye diseases or procedures

Eye diseases in the family

Are you currently taking any medication?

Current Medications with Dosage

Are allergies or intolerances known?

Known allergies and intolerances

Other relevant information

What would you like to discuss personally?

Additions or uncertainties Please mark uncertain information. Adapt professionally and regarding data protection by the institution before use. No diagnostics, triage, or medical advice. Not for emergencies.