THE EYE, A WINDOW ON THE BODY

The eye is a window on this inseparable unity which is the human body. That is why the ophthalmic examination aims to find not only solution for your ocular complaints, but also to detect eye illnesses (cataract, glaucoma, etc.) and certain general diseases (arterial hypertension, diabetes, etc.).

To optimise your consultation, Doctor SAFFIEDINE invites you to return this form completed IN CAPITAL LETTERS, with most details possible. The data of this document are covered by the medical Secret. You are kindly requested to deliver your identity card and all your spectacles at the reception for their measurements.  Dr. SAFFIEDINE thanks you for your cooperation.


Family name (maiden name):
Forename:
Identity card number:
Address in your country of origin:
Telephone in your country of origin:
Mobile in your country of origin:
Address in TENERIFE:
Telephone in TENERIFE:
Mobile in your TENERIFE:
Date of birth:
Profession:
Name and land of your Private Health Insurance:
Who advised you to consult Dr SAFFIEDINE?
Data of your family doctor:
Identity card number:

Questions about your general health (Please, go into the details):

 

  • Have you ever been operated on?
    • Of? When?
  • Have you ever been seriously ill?
    • Of? When?
  • Do you have allergy to food? Pollen? Pets? Medications? Other?
    • If yes, detail please:
  • Do you have asthma?
  • Did you ever stay more than one day in a tropical land?
    • If so, Where? From when to when?
  • Did you ever have a cerebral commotion?
    • If so, when?
    • With lost of consciousness?
  • Are you diabetic?
    • If so, since when? If you take Insuline, since when?
    • When were measured and what are the levels of your last glycaemia? HbAc?
  • Is your blood pressure high?
    • If so, since when?
    • How much was the highest blood pressure you ever had?
    • When was measured, for the last time, your blood pressure?
  • Do you smoke?
    • If so, since when?
    • How many cigarettes per day?
  • Do you have often headache?
    • If so, at which part of the head?
    • What kind of pain is it: Pressure around the brain? Pulsations? A forehead bar?
    • Mostly when: At the wake up? In the morning? In the evening? At night? During the sleep?
    • At which frequency: once a month? Once a week? Every 3 to 4 days? Every day? Every 2 to 3 hours? Permanently?
    • What are the medications you take in case of headache? At what frequency?
    • What are the medications you take?
    • Other:

Questions on the ocular status:

  • Are there serious eye illnesses in your family? (Strabismus, glaucoma, cataract, retinal detachment, etc.)
  • Do you have any colour vision defects?
  • Did you have a squint during your childhood?
  • Do you have an eye that never saw well? Which one?
  • Did you ever have a serious eye disease, inflammation, infection?
    • If so, go into the details:
  • Did you ever have an eye injury?
    • If so, go into the details:
  • Do you wear optical correction spectacles?
    • At what age did you put your first spectacles?
    • When was the last time you changed the glasses of your spectacles?
  • Do you wear contact lenses?
    • At what age did you put your first contacts?
    • When was the last time you changed the power of your contacts?
    • What is the trade mark of your contacts? Of the cleansing products?
  • Other:

 

  1. The drops instilled in your eyes allow a thorough examination and reliable results. Nonetheless, they blur the vision and render the eyes more sensitive to bright light during one to two hours. 
  2. The preliminary examinations you will undergo allow the detection of optical defects, some optic nerve and retinal diseases and some dysfunctions in the connexions between the eyes and the brain.
  3. In compliance with the Organic Law 15/1999 of December 13, concerning the Protection of Personal Data, you are informed that the data you provide by filling in this form and the documents provided to DR. SAFFIEDINE will become part of a file owned by DR. SAFFIEDINE and used only for the provision, management and administration of contracted services. Also, you can exercise your rights of access, rectification, cancellation and opposition to DR. SAFFIEDINE C / Luís Díaz de Losada, 5, 38660, Playa De Las Américas, Tenerife. DR. SAFFIEDINE is in no way responsible of the legality, accuracy of the information provided by you. It is your sole responsibility to notify to DR. SAFFIEDINE any changes in them.
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