Connecticut Retina Consultants

Welcome to Connecticut Retina Consultants

Established in 1990, Connecticut Retina Consultants offers comprehensive care of medical and surgical retinal diseases, including macular degeneration, diabetic retinopathy, retinal detachment, retinal venous occlusive disease and uveitis. Our doctors are all expertly trained to treat these complex retinal problems. The first group in Connecticut to perform complex retinal operations including macular hole surgery and pneumatic retinopexy, our doctors continue to be the most accomplished vitreo-retinal surgeons, at the leading edge of retinal and uveitis care. Convenient in-office laser, ultrasound, fluorescein angiography, and ocular coherence tomography (OCT) services allow rapid diagnosis and treatment. Many surgical procedures can be performed in the office as well. For more complicated procedures, outpatient, local anesthesia is used. Available for consultation and second opinions, we have convenient locations in New Haven, Bridgeport, Hamden, Madison, and Norwalk.

On the day of your appointment, please bring the following with you

- Your photo ID
- Current health insurance card(s)
- A completed Patient Registration form (enclosed)
- A completed Medical History form (enclosed)
- If you wear eyeglasses please bring them to your appointment
- A list of any medications, including dosage

Your eyes will be fully dilated to ensure a thorough retinal exam, and may be dilated for 21-36 hours afterward. For safety, we recommend that someone drive you home from each visit.

Thank you again for choosing Connecticut Retina Consultants! We look forward to serving you!

Name:

Date of Birth:

Age:

Date:

Height:

Weight:

Primary Care Physician:

Gender:

Male Female

CONDITIONS

GENERAL:

fever Heat stroke Weight loss Weight gain Fatigue Insomnia Headaches None

EARS, NOSE, THROAT:

Hard of hearing Ear ache Cough Dry mouth Sinus/allergy Hoarseness Vertigo None

RESPIRATORY:

Congestion Wheezing Short of breath Asthma COPD Emphysema TB exposure None

GASTROINTESTINAL:

Stomach upset Diarrhea Constipation Hernia Ulcers Nausea GERD, None

GENITOURINARY:

Painful/ frequent urination Impotence Yellow jaundice Kidney stones Blood in urine None

ENDOCRINE:

Diabetes Hypothyroid Hyperthyroid Hormone Increased thirst Graves Disease Thyroid Eye Disease None

FEMALES:

Are you pregnant? Are you nursing? None

PSYCHIATRIC:

Anxiety Depression None

CANCER:

Breast Prostate Lung Skin Colon Other None

DERMATOLOGIC:

Pimples Acne Warts Growths Rash Rosacea Melanoma None

MUSCULOSKELETAL:

Joint pain Stiffness Swelling Cramps Fibromyalgia Rheumatoid arthritis Lupus Other type arthritis Osteoporosis None

NEUROLOGICAL:

Numbness Headache Seizures Paralysis Stroke Dementia Memory loss Alzheimer’s Parkinson’s None

HEMATOLOGY:

Bleeding Anemia Blood clots Problems related to blood transfusions None

ALLERGIC/IMMUNOLOGIC:

Sinus Sneezing Swelling Redness Itching Hives Lupus HIV Herpes Simplex Virus Sjogren’s Syndrome Rheumatoid arthritis None

EYES:

Cataract Glaucoma Detached retina Blindness Lazy eye Eye injury/trauma Corneal problems Macular degeneration None

CARDIOVASCULAR:

High B/P Heart attack Chest pain Congestive heart failure Racing pulse High cholesterol Irregular heartbeat Palpitations Pace maker None

List all Eye Surgeries & Laser Eye Surgeries:

List all OTHER surgeries you have had: