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Iworks Team
Dr. Patrick L. Spencer
Staff
Testimonials
Cataracts
What is a Cataract
Traditional Cataract Surgery
Laser Cataract Surgery
Frequently Asked Questions
Lasik
ALL Laser Lasik Surgery
Cutting Edge Laser Suite
What’s New!
Dextenza Insert for Cataract Surgery!
Eyelid “Uplift” with Upneeq
Our Office
Optical Shop
Contact Lenses
Media Gallery
Vision Seminar
Learn More
Cosmetic Procedures
Cosmetic Botox
Our Technology
3D Wavescanner
Sports Vision Assessment
Optical Coherence Tomography (OCT)
Astigmatism
Blepharitis
Cataracts
Conjunctival Problems
Corneal Disorders
Diabetic Retinopathy
Dry Eyes
Episcleritis and Scleritis
Eye Strain
Flashes and Floaters
Glaucoma
Hyperopia
Macular Degeneration ARMD
Retinal Disorders
My Visit Info
Patient Forms
Patient Sign-In
CareCredit Financing
Patient Medical History
Please fill this form out, or
download our printable forms here
Social History
Full Name
*
Current Occupation
*
Previous Occupation
*
Do you drive?
*
Please select an option
Yes
No
Do you have visual difficulty when driving?
*
Please select an option
No
Yes
Do you have problems with night vision?
*
Please select an option
No
Yes
Do you Drink Alcohol?
*
Please select an option
No
Yes
How often do you drink alcohol?
*
Do you Smoke?
*
Please select an option
No
Yes
how many cigarettes/pack(s) a day?
*
Do you currently wear glasses/contacts?
*
Please select an option
No
Yes
How long have you had the current prescription?
*
List all major illnesses and injuries
List non-eye based surgeries
List eye surgeries
Detailed Eye History
Loss Of Vision
No
Yes
Explanation Of Problem (Loss Of Vision)
*
Blurred Vision
No
Yes
Explanation Of Problem (Blurred Vision)
*
Distorted Vision (HALOS)
No
Yes
Explanation Of Problem (Distorted Vision (HALOS))
*
Double Vision
No
Yes
Explanation Of Problem (Double Vision)
*
Dryness
No
Yes
Explanation Of Problem (Dryness)
*
Mucous Discharge
No
Yes
Explanation Of Problem (Mucous Discharge)
*
Redness
No
Yes
Explanation Of Problem (Redness)
*
Sandy or gritty feeling
No
Yes
Explanation Of Problem (Sandy or gritty feeling)
*
Itching
No
Yes
Explanation Of Problem (Itching)
*
Burning
No
Yes
Explanation Of Problem (Burning)
*
Tearing/ Watering
No
Yes
Explanation Of Problem (Tearing/ Watering)
*
Glare/Light Sensations
No
Yes
Explanation Of Problem (Glare/Light sensations)
*
Eye Pain Or Soreness
No
Yes
Explanation Of Problem (Eye Pain Or Soreness)
*
Styes, Chalazions
No
Yes
Explanation Of Problem (Styes, Chalazions)
*
If you have any issues in the areas of your body listed below, please check the box next to it.
Current Issues
Sinus congestion
Runny nose
Chronic Cough
Chronic Bronchitis
Cardiovascular (Heart/Blood Vessel)
Gastrointestinal (Stomach/Intestines)
Genitourinary (Genitals/Kidneys/Bladder)
Muscle Problems
Arthritis Problems
Integumentary (Skin and/or Breast)
Neurological Problems
Psychiatric Problems
Endocrine Problems
Blood Problems
Lymph Node Problems
Swelling Problems
Head Allergy Symptoms
Seasonal Allergies
Inflamatory Conditions
Please specify your respiratory issues (Ear, Nose, Mouth, Throat, Lungs)
*
Please specify your Cardiovascular (Heart/Blood Vessel) issues
*
Please specify your gastrointestinal issues (Stomach/Intestines)
*
Please specify your Genitourinary (Genitals/Kidneys/Bladder) issues
*
Please specify your Musculoskeletal issues (Muscles problems, arthritis problems)
*
Please specify your Integumentary (Skin and/or Breast) issues
*
Please specify your Neurological issues
*
Please specify your Psychiatric issues
*
Please specify your Endocrine issues
*
Please specify your Hematologic / Lymphatic issues (Blood, Lymph Nodes, Swelling)
*
Please specify your Allergic / Immunologic issues (Allergies, Inflammatory Conditions)
*
If any of the below issues run in your family, please check the box:
Family History
Blindness
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Arthritis
Cancer
Diabetes
Heart Attacks
High Blood Pressure
Kidney Disease
Lupus
Dry eye problems
Stroke
Thyroid Disease
Lymph Node Problems
Tuberculosis
Other Diseases
Which family members have a history of Blindness?
*
Which family members have a history of Cataracts?
*
Which family members have a history of Glaucoma?
*
Which family members have a history of Macular Degeneration?
*
Which family member(s) have a history of Retinal Detachment?
*
Which family member(s) have a history of Arthritis?
*
Which family member(s) have a history of Cancer?
*
Which family member(s) have a history of Diabetes?
*
Which family member(s) have a history of Heart Attacks?
*
Which family member(s) have a history of High Blood Pressure?
*
Which family member(s) have a history of Kidney Disease?
*
Which family member(s) have a history of Lupus?
*
Which family member(s) have a history of Dry eye problems?
*
Which family member(s) have a history of Stroke?
*
Which family member(s) have a history of Thyroid Disease?
*
Which family member(s) have a history of Lymph Node Problems
*
Which family member(s) have a history of Tuberculosis?
*
What other diseases are in your family history?
*
Submit