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Patient Questionnaire: Blepharoplasty / Eyelid Surgery

If you are interested in eyelid improvement, please print this form, complete it, and mail it to Becky Smith (Cosmetic Coordinator), or Sheila Ferguson, Beth McCauley, Sandra Page, or Patricia Tucker-Horne (patient advocates) at Dermatology Associates of Atlanta at the address at the bottom of the page. Or, you may fax the form to us at 404-843-3469 or you may complete it and e-mail it directly to us online. Be aware that the security and confidentiality of information over the internet cannot be guaranteed. Our patient base extends to many parts of the country and a member of our staff would be happy to speak with you personally about your goals and desires.

Please tell us more about you. This medical information is intended as an informational service for internal purposes only.

Name:

E-Mail:

Date:

Address:

Daytime Phone Number:

Age:

Date of your last eye exam:

At your last eye exam, were you told that you have any problems with your eyes?

If so, please explain:

Do you require eyeglasses or contact lens?

Which one?

Have you had any injuries or surgeries to the eyes or eyelids?

Please describe:

Do you now or have you ever, taken medication or drops for the eyes?

If so, what?

Are you bothered by "dry eyes"?

Do your eyes "water" or "tear" spontaneously?

Do you now have or have you ever had any visual problems?

If yes, please describe:

Please rate your general health:

Good
Fair
Poor

Please list any medical problems known to you:

Please check if you have a history of the following:

High blood pressure
Bleeding / Clotting problems
Heart condition (including murmur or mitral valve prolapse)

Please list any allergies:

Please list previous surgeries and note if you have had eyelid surgery in the past:

Have you had complications from any surgery or anesthesia?

If yes, please describe:

Thank you. We look forward to speaking with you and meeting you in the future.

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