New Patient, Adult Form

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10120 S. Eastern Ave., Suite 165

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Our Practice
Patient Center
Glasses & Contacts
Appointment Request
Contact Us

10120 S Eastern Ave Ste 165

Home
Our Practice
Patient Center
Glasses & Contacts
Appointment Request
Contact Us

Home
Our Practice
Patient Center
Glasses & Contacts
Appointment Request
Contact Us

Home » New Patient, Adult Form

New Patient, Adult Form

WELCOME TO ENVISION EYECARE
We appreciate you choosing us for child's professional eye care.
Today's Date*
Name*
Prefix First Middle Last
Nickname
Marital Status
- Single
- Married
- Widowed
- Divorced
Date of Birth*
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Preferred Phone Number
Email*
Preferred Language
Have we taken care of your family members?*
- Yes
- No
Whom?
May we thank someone for referring you?
- Yes
- No
Whom?
Medical Insurance
Vision Insurance
Policyholder's Name
Policyholder's Employer
Lifestyle Questionnaire
This will allow us to make recommendations for your child's eye care needs!
What the Reason(s) for your Visit Today?
When was your last eye exam?
Are you having vision problems without glasses?
- Yes, distance
- Yes, computer
- Yes, near
- No
Glasses
If you select yes, please answer the additional questions.
Do you wear glasses?*
- Yes
- No
Are you having problems with your glasses?
- Yes, distance
- Yes, computer
- Yes, near
- No
Are you interested in getting new glasses?
- Yes
- If my prescription changes
- No
Do the glasses have an anti-glare lenses?
- Yes
- No
Do you have prescription sunglasses?
- Yes
- No
Contact Lenses
Do you wear contact lenses?*
- Yes
- No
Do you want to try them?*
- Yes
- No
Are you interested in colored contacts?*
- Yes
- No
Refractive Surgery
Are you interested in laser surgery?
- Yes
- No
Activities
Employer
Occupation
Is it difficult to see when driving during the day?
- Yes
- No
Is it difficult to see when driving during at night?
- Yes
- No
How many hours per day do you use the computer?
Do you spend time outdoors?
- Yes
- No
How many hours per week?
What hobbies do you enjoy?
Do these activities strain your eyes?
- Yes
- No
Social History
Please check the box if you prefer to discuss the following information with the doctor only.
- Yes
Do you use tobacco products?
- Yes, every day
- Yes, some days
- No, never
- No, former smoker
Do you drink alcohol?
- Yes
- No
Type / Amount / How Long:
Do you use illegal drugs?
- Yes
- No
Type / Amount / How Long:
Ocular History
Do you have any eye problems?
(please select all that apply)
- Cataracts
- Macular Degeneration
- Glaucoma
- Diabetic
- Dry Eye
- Eye Infections
- Allergies
- Floaters
- Flashes
- Iritis / Uveitis
- Retinal Detachment
- Redness
- Burning
- Itching
- Watery Eyes
- Mucus Discharge
- Eyestrain/Tired Eyes
- Blurred Vision
- Eye Pain
- Light Sensitivity
- Headaches
- Poor Night Vision
- Glare
- Double Vision
- Vision Loss
- Eye Surgery
- Lazy Eye
- Eye Turn/Patching
- Keratoconus
- Eye Injury
- Nystagmus
- Droopy Eyelid
- Other
Please Explain Other:
Medical History
Name of Medical Doctor
Last Medical Exam
Do you take medication?
- No
- Yes
- Provide List
Please list medications:
Medication Reason
Do you have any allergies to medications?*
- Yes
- No
Please list name of the medication and reaction:
Medication Reaction
List all major injuries, surgeries and/or hospitalizations.
Are you pregnant?
- Yes
- No
Are you nursing?
- Yes
- No
Review of Systems
Please select all that apply. For Other, please fill-in the blank box.
Constitutional
- Developmental disabilities
- Fatigue
- Cancer
- Other
Type of Cancer:
Please Explain Other:
Ears, Nose, Throat
- Hearing loss
- Sinusitis
- Dry mouth
- Laryngitis
- Other
Please Explain Other:
Neurological
- Multiple Sclerosis
- Epilepsy
- Cerbral Palsy
- Tumor
- Migraine
- Other
Please Explain Other:
Psychiatric
- Depression
- Attention deficit (ADHD)
- Anxiety
- Bipolar
- Other
Please Explain Other:
Cardiovascular
- High blood pressure
- Stroke
- Heart disease
- Vascular disease
- Congestive heart failure
- Other
Please Explain Other:
Respiratory
- Asthma
- Bronchitis
- Emphysema
- Chronic obstruction
- Sleep Apnea
- Other
Please Explain Other:
Gastrointestinal
- Crohn's
- Colitis
- Ulcer
- Acid reflux
- Celiac disease
- Other
Please Explain Other:
Genitourinary
- Kidney Disease
- Prostate Disease
- Herpes
- Chlamydia
- Other
Please Explain Other:
Musculoskeletal
- Osteoarthritis
- Arthritis
- Fibromyalgia
- Muscular dystrophy
- Ankylosing Spondylitis
- Osteoporosis
- Gout
- Other
Please Explain Other:
Integumentary
- Eczema
- Rosacea
- Psoriasis
- Cold Sores
- Shingles
- Other
Please Explain Other:
Endocrine
- Type 2 Diabetes
- Type 1 Diabetes
- Hypothyroid
- Hyperthyroid - Grave's Disease
- Hormone problems
- Other
Please Explain Other:
Hematologic/Lymphatic
- Anemia
- Blood Loss
- Ulcer
- High Cholesterol
- Other
Please Explain Other:
Allergic/Immunologic
- Food Allergies
- Fluorescein Allergy
- Environmental Allergies
- Rheumatoid Arthritis
- Lupus
- Sjogren's
- HIV
- Gonorrhea
- Hepatitis
- Syphilis
- Other
Please Explain Other:
Family History
List the family member(s) that has/had the following: (Ex. Mother, Grandparent, etc)
Heart Disease
Macular Degeneration
High Blood Pressure
Lazy Eye / Amblyopia
Diabetes
Eye Turn / Strabismus
Cancer
Nystagmus
Thyroid Disease
Retinal Detachment / Disease
Cataract
Arthritis
Glaucoma
Lupus

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Envision Eyecare

Phone: 702-456-9585
Fax: 702-456-0011
Email: info@envisionnv.com
(Do not send personal health information by email.)

10120 S. Eastern Ave., Suite 165
Henderson, NV 89052

LOCATION

ErikaDuggan Rotating2Office2

10120 S. Eastern Ave., Suite 165
Henderson, NV 89052

Phone: 702-456-9585
Fax: 702-456-0011
Email: info@envisionnv.com
(Do not send personal health information by email.)

HOURS

Monday: 08:00 AM - 6:00 PM
Tuesday: 08:00 AM - 6:00 PM
Wednesday: 08:00 AM - 6:00 PM
Thursday: 08:00 AM - 6:00 PM
Friday: 08:00 AM - 04:00 PM
Saturday: Closed
Sunday: Closed

Closed Daily: 1:00 PM - 2:00 PM

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