Joseph L. Demer, MD, PhD

Pediatric Ophthalmology and Strabismus Division
Jules Stein Eye Institute

Thank you for taking the time to print and complete this questionnaire.   Please type or print all items clearly and bring the completed questionnaire to the appointment.  The information it contains will be kept in strict confidence.

	Personal Information Name Age Gender Male Female Birth Date (ex.  mm/dd/yyyy) Occupation

	Referring Doctor Name Address City State Zip Code Phone

	Your Eye Problem Which eye is affected? Left Right Both How long has the problem been present? State briefly the problem you are having with your eye(s) Is the problem: getting better   getting worse   staying the same?

	Your Medical History List all previous surgery, including eye surgery, with dates: List all non-surgical (medical) hospitalization with dates: Check any of the following problems that apply to you: asthma emphysema kidney disease bronchitis heart disease migraines cancer hypertension neurologic disorders diabetes infections thyroid problems Other problems Allergies (to medicines): none

	List the medicines you currently take (pills and eyedrops): Medicine Strength (mg or % you take each time) Dosage (how many pills / drops each time?) Frequency (how many times per day?) Start