Retina Specialist Intake Form

This retina specialist intake form is designed specifically for ophthalmologists who focus on vitreoretinal diseases and surgical interventions. It captures critical information about vision changes, floaters, flashes of light, and symptoms specific to retinal conditions including age-related macular degeneration, diabetic retinopathy, retinal vein occlusion, and retinal detachment. The form includes targeted questions about diabetes management, previous eye surgeries, and family history of retinal diseases.

The template enables retina practices to efficiently gather patient history before the initial consultation, including current medications that may affect surgical outcomes, detailed symptom timelines, and previous treatments like anti-VEGF injections or laser photocoagulation. By collecting this specialized information upfront, retina specialists can optimize appointment time and prepare appropriate diagnostic equipment for each patient's specific condition.