Lens Replacement - Beauty In Prague

PLEASE NOTE: It is necessary to provide us with all medication you use for all health problems in order to correctly indicate you to a surgery. In case if false, not complete information or concealed medical history is provided your treatment might be cancelled with no financial refund.

Name and Surname: *

Country:

Phone:

E-mail: *

Considered date for the treatment: *

Date of Birth: *

Weight: *

Height: *

Do you wear glasses for distance?

YesNo

Do you wear glasses for near vision/ reading glasses?

YesNo

Do you know your prescription - for both long and short distance?

1. Are you fit and well?

YesNo

2. Have you had any eye operations in the past?

YesNo

3. Do you use any eye drops?

YesNo

4. Do you regularly attend hospital for your eyes?

YesNo

5. Do you suffer from any auto immune disease?

YesNo

6. Have you had any operation in the past? (heart, kidney etc.)

YesNo

7. Do you suffer from a lazy eye (amblyopia)?

YesNo

8. Have you ever had any eye injury?

YesNo

9. Do you suffer from heart disease, or have you ever had problems with your heart?

YesNo

10. Are you being treated for high blood pressure?

YesNo

11. Is anyone of your relatives being treated for glaucoma?

YesNo

12. Do you suffer from any respiratory disorder?

YesNo

13. Do you receive treatment for diabetes?

YesNo

14. Are you being treated for a nervous disease?

YesNo

15. Are you at present suffering from a cold or influenza?

YesNo

16. Have you ever been admitted to hospital or been treated / taken medication for a mental illness?

YesNo

Drug Reactions/Allergies: Please list below any known drug allergies or reactions, or sensitivities.

Prescription Medications: Please list all prescription medications you currently take:

Non-Prescription Medications / Dietary Supplements / Vitamins / Herbs / Minerals: If you currently take items in this category, please list below.

Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray)
Please indicate your current status regarding these items below: Do you SMOKE or use TOBACCO/NICOTINE PRODUCTS?

YesI am a NON SMOKER and do not use nicotine products.

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