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E – Consultation

Patient Information

Male Female

Contact Information

Main Complaints

  • Reduced Vision
  • Watering
  • Pain
  • Redness
  • Glare
  • Double Vision
  • Closing Of Eyelids
  • Sticking Of Eyelashes
  • Squint
  • Haloes
  • Headache
  • Or Any Ocular Medication
Yes No

Personal History

  • Diabetes Mellitus
  • Hypertension
  • Thyroid
  • Heart Disease
  • Retinal Disease
  • Injury
  • Other Diseases
  • Smoker
  • Alcoholic

Family History

  • Glaucoma
  • Squint
  • Retinal Detachment
  • Myopia
  • Diabetes Mellitus

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