Medical History Form

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Disease/Condition

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer

Do you current, or have you ever had any problems in the following areas?

Dilated Fundus Examination

Pupil dilation is absolutely recommended for all of our patients. Pupil dilation allows a doctor to examine the retina for holes, tears, detachment, tumors (benign or malignant), leaking blood vessels and other retinal anomalies. Dilation is especially helpful in the diagnosis of glaucoma, cataracts, unexplained vision decrease, and even brain tumors. Having the pupils dilated for your exam can literally save the vision by detecting problems earlier in their development.

People with a personal or family history of headaches, diabetes, hypertension, or who have a personal history of head or eye injuries, or who have had a comprehensive dilated eye exam, or who have a high prescription are particularly at risk and must have a comprehensive dilated eye exam regularly.

The most common side effects of the drops used are increased light sensitivity and reduction in near focusing ability. Distance vision is not significantly affected and most people have no trouble driving after. If you do not have sunglasses with you we will provide post-dilation glasses, and would be happy to help you obtain proper sun protection for future use. The process is painless, and lasts approximately 4 to 5 hours.

I understand the importance of pupil dilation in a complete eye examination

RETINAL IMAGING

We are pleased a announce the incorporation of retinal imaging into our practitice. This is a sophisticated high tech instrument that allows us to provide a more thorough medical evaluation of your eye.

Our retinal imaging device captures a digital image of the central and peripheral retinal showing the blood vessels, macula and optic nerve. This picture is permanently stored in a computerized database for analysis and future reference to monitor change in your eye.

Unfortunately, routine eye exams for glasses do not detect many diseases in their early stages. This wide angle retinal photography scan assist in the early detection of many diseases including brain tumors, glaucoma, diabetic retinopathy, detachment, Optic nerve disease and retinal disturbances due to systemic medications.

This imaging is especially important for patients who have or have had:

1. History or family history of Glaucoma
2. History of headache/Migraines
3. History or family history of Diabetes
4. History or family history of High Blood Pressure
5. Spots in their vision and/or flashes of light
6. High degree of near-sightedness/high eye glasses prescription

This procedure takes less than 5 minutes of your time and is an additional charge for it as this is not covered by vision plans. This change is in addition to any insurance co-payment or deductible you may have.

Dr. Osayi recommends that retinal imaging be done yearly as part of your routine eye health exam.