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Welcome to Dr. Anthony Foti's office
In order to learn all about your eyes and visions, we need to know about your general health status. Please take a few minutes to answer the following questions about your health and eyes.
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Name
Your answer
Date of Birth
Your answer
Address
Your answer
City
Your answer
Home phone
Your answer
Cell
Your answer
Email address
Your answer
When was your last eye exam
Your answer
Who provided your last exam?
Your answer
Have you ever worn prescription eyeglasses?
Yes
No
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Do you wear prescription eyeglasses now?
Yes
No
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Do you see clearly with glasses when reading books?
Yes
No
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Do you see clearly with glasses when looking far away? ( i.e. driving)
Yes
No
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Do you wear contact lenses?
Yes
No
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If yes, who provides your contact lens care?
Your answer
Do you have sharp pain in your eye?
Yes
No
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Do you see double when there is just one object present?
Yes
No
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Do you see halos and/ or rings around lights at anytime of the day?
Yes
No
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Have you ever had any medical or surgical treatment on your eyes?
Yes
No
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If so, what were the procedure?
Your answer
Have you ever been diagnosed with an eye disease? (Cataracts, glaucoma, retinal detachment, etc)
Yes
No
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If yes, what was the diagnosis?
Your answer
Is there any eye disease in your family?
Yes
No
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Who provided your last physical exam or general medical check up exam? What was the day?
Your answer
Are your currently under a follow-up for any medical conditions?
Yes
No
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Are you currently taking any medications?
Yes
No
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If yes, please list:
Your answer
Are you allergic to any drugs, chemicals, or medications?
Yes
No
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if yes, please list:
Your answer
Is there anything else about your eyes, vision or general health that you think the Doctor should know about before your exam?
Yes
No
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If yes, please list:
Your answer
Insurance type:
Your answer
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