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This is what is considered a Review of Systems (ROS)
by filling this out prior to your visit, Dr. Gee will be able to review your chart and expedite your visit


Please answer the following questions for
you or your immediate family
(mother, father, siblings and children)

"Y" for yes or "N" for no
If you answer "Y" please describe.  Thank you. 


First Name
Last Name
Date of Birth (xx/xx/xxxx)
AIDS/HIV+ (self/family)
Anemia (self/family)
Asthma/Bronchitis (self/family)
Autoimmune Disorders ie. Lupus, Sjogren's, Crohn's (self/family)
Cancer (self/family) type
Diabetes (self/family)
Emphysema (self/family)
Epilepsy/Seizure (self/family)
Hepatitis (self/family)
Heart Disease/Attack (self/family)
High Blood Pressure (self/family)
High Cholesterol (self/family)
Lung Disease (self/family)
Kidney Disease (self/family)
Stroke (self/family)
Thyroid Disorder (self/family)
Gastrointestinal Disorders (self/family)
Cataracts (self/family)
Glaucoma (self/family)
Macular Degeneration (self/family)
Retinal Detachment (self/family)
Other (please describe)
Previous Surgeries (body and eye)
Do you smoke? If "Yes" how many packs/day and for how long?
Do you consume alcohol? If yes, how much?
Please list your medications
medications continued
Allergies (drug/environmental)
Females, are you/could you be pregnant?
Blurry Vision?
Dry Eyes?
Itchy Eyes?
Floaters?
Watery Eyes?
Pain in/around eyes?
Do you wear contacts? If "Yes" what type?
Interested in refractive surgery?

Copyright 2012. Gee Eye Care. All Rights Reserved

Gee Eye Care, P.A.                             P.O. Box 18075                    Sugar Land, Texas 77496

Serving Sienna Plantation and surrounding areas