Ophthalmology Medical History: Upper and Lower Eyelids

Please complete this form before your eyelid visit. It takes about 10 minutes. Fields marked * are required.

Do not use this form for an emergency. If you have sudden vision loss, a new curtain or shadow over your vision, a sudden shower of flashes or floaters, severe eye pain, or an eye injury, call the office right away or go to the nearest emergency room.

Sudden vision loss, flashes, or new floaters can be an emergency. If this is happening now, please call the office or go to the emergency room today instead of waiting for your visit.

1. About you and your visit

Last nameFirst nameMiddle initial Date of birthPhoneEmail Referring doctorPrimary care doctor Eye doctor (optometrist or ophthalmologist) What is the main reason for your visit today?

Which eyelids are affected?

UpperLowerBoth upper and lower

Which side?

RightLeftBoth

How long have you had this problem?

Is it:

Getting worseStaying the sameComes and goes

What are you hoping for from this visit? Check all that apply.

See betterComfortAppearanceDiagnosis of a growth or bump

Other goal

2. Upper eyelids

Do you have…	Yes	No	Which eye
Droopy upper eyelid(s)
Extra or heavy skin on the upper lids
Lids or skin that block your upper or side vision
Droop that is worse when tired or at the end of the day
Droop that changes during the day, or double vision
Lifting your eyebrows or tilting your head back to see
Forehead or brow tiredness, or headaches from raising brows
Droopy eyebrows
Eyelid that does not close fully (including during sleep)
Swelling or puffiness of the upper lids
Eyelid twitching or forceful blinking / squeezing
Lump, bump, or growth on the lid
Lid lesion that bleeds, crusts, grows, or has lost lashes

How do your upper lids affect daily life? Check all that apply.

When did you first notice the droop or extra skin?

3. Lower eyelids

Do you have…	Yes	No	Which eye
Lower lid that sags or turns outward (away from the eye)
Lower lid that turns inward, or lashes rubbing the eye
Watery eyes or tears running down the cheek
Gritty, sandy, or burning feeling
Red, irritated eyes
Mucus or discharge, or lids stuck together in the morning
Bags or puffiness under the eyes
Dark circles or hollows under the eyes
White of the eye showing below the colored part
Crusting, flaking, or redness along the lash line
Styes or chalazia (lid bumps) that keep coming back
Lump, bump, or growth on the lower lid
Lid lesion that bleeds, crusts, grows, or has lost lashes
Swelling or pain near the inner corner of the eye, by the nose

How often do you wipe tears?

RarelyA few times a dayMany times an hour

4. Your eyes and eye history

Eye symptoms now. Check any you have.

Eye history

Question	Yes	No	Details (which eye, when)
Wear glasses
Wear contact lenses (hard / soft)
Cataract surgery
LASIK or other laser vision surgery
Glaucoma, or use pressure-lowering drops
Macular degeneration or retina problems
Dry eye disease
Blepharitis (lid inflammation) or rosacea of the eyes
Lazy eye, eye muscle problems, or eye muscle surgery
Eye or face injury, or broken bones around the eye
Previous eyelid surgery (blepharoplasty, ptosis, lid tightening)
Previous eyebrow or forehead lift
Skin cancer removed from the eyelid or face
Tear duct problems or tear duct surgery
Botox or fillers around the eyes (date of last treatment)
Radiation treatment to the head or face

Eye drops and ointments you use (name, which eye, how often)

5. Medical history, medicines, and allergies

Do you have or have you had…	Yes	No
Thyroid disease (Graves' disease, overactive or underactive thyroid)
Myasthenia gravis or other muscle weakness
Bell's palsy, facial paralysis, or stroke
Diabetes
High blood pressure
Heart disease, pacemaker, or heart stent
Bleeding or clotting problems, or easy bruising
Skin cancer (anywhere)
Rosacea, eczema, or psoriasis
Autoimmune disease (lupus, rheumatoid arthritis, Sjögren's)
Sleep apnea, or use a CPAP machine
Allergies or hay fever
Kidney disease
Problems with anesthesia or sedation
Keloids or poor wound healing
Pregnant or could be pregnant

Other conditionsPast surgeries (any, with year)

Blood thinners and supplements. These can cause bleeding with eyelid surgery. Do you take:

All other medicines (name and dose)Allergies: list medicines and what happens

Also allergic to:

6. Family and social history

Has a parent, brother, sister, or child had:

Do you smoke or vape?

NeverFormerCurrent

If former: year you quitIf current: how muchAlcoholic drinks per week

Do you drive?

YesNo

OccupationHobbies that need good vision (reading, sewing, sports)Who can drive you home after a procedure?

7. Signature

I confirm this information is complete and correct to the best of my knowledge. I agree that photographs of my eyes and face may be taken for my medical record and insurance review.

I agree to the statement above

Type your full name as your signature (patient or guardian)Date

Thank you. Your form was sent.

Please bring your glasses, a list of your eye drops, a photo ID, and your insurance card to your visit.

Condition	Yes	No	Who
Droopy eyelids
Glaucoma
Macular degeneration
Thyroid eye disease
Skin cancer
Bleeding problems
Problems with anesthesia