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Name
Phone
Country
Age
Height
Weight
Address with postal code
Have ever consulted/ this Centre before?
Any other treatment history
Family history of this disease
How long patient is suffering from this disease.land what was the first symtom noticed?
What about acuity of vision.(means how many lines you can read of eye chart from distance of 20 feet.)If patient is unable to read any line of eye chart from 20 feet try to get reading from minimum distance 10 feet or 2-3 feet.
What is near vision? (can he read news paper easily?or headlines of news paper?)
Does patient feels eye fatigued in normal reading.
Does patient sees floaters if yes since when and what is the frequency and disturbance caused by floaters
Sides vision and lowers side vision
What is color vision?
Does patient feels difficulty in night.
Does patient feels difficulty in sunlight?
When patient is more comfortable day or night?
Any other difficulty in vision?
History of diabetes uncontrolled hypertension heart ailment epilepsy smoking. Tobacco chewing habits and any other chronic ailment
Tongue photograph of patient This is for traditional diagnosis --it can be done simply at home by any camera and can be taken just by protruding tongue take a color photo scan and mail.
Is there any period in which vision deteorated very fast if yes please mention