New Patient, Adult Form WELCOME TO ENVISION EYECAREWe appreciate you choosing us for child's professional eye care.Today's Date* Date Format: MM slash DD slash YYYY Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last NicknameMarital StatusSingleMarriedWidowedDivorcedDate of Birth* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePreferred Phone Number--Please Select--HomeCellWorkEmail* Preferred LanguageHave we taken care of your family members?*YesNoWhom?May we thank someone for referring you?YesNoWhom?Medical InsuranceVision InsurancePolicyholder's NamePolicyholder's EmployerLifestyle QuestionnaireThis 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 GlassesIf you select yes, please answer the additional questions.Do you wear glasses?*YesNoAre you having problems with your glasses? Yes, distance Yes, computer Yes, near No Are you interested in getting new glasses?YesIf my prescription changesNoDo the glasses have an anti-glare lenses?YesNoDo you have prescription sunglasses?YesNoContact LensesDo you wear contact lenses?*YesNoDo you want to try them?*YesNoAre you interested in colored contacts?*YesNoRefractive SurgeryAre you interested in laser surgery?YesNoActivitiesEmployerOccupationIs it difficult to see when driving during the day?YesNoIs it difficult to see when driving during at night?YesNoHow many hours per day do you use the computer?Do you spend time outdoors?YesNoHow many hours per week?What hobbies do you enjoy?Do these activities strain your eyes?YesNoSocial HistoryPlease check Yes if you prefer to discuss the following information with the doctor only.YesNoDo you use tobacco products?Yes, every dayYes, some daysNo, neverNo, former smokerDo you drink alcohol?YesNoType / Amount / How Long:Do you use illegal drugs?YesNoType / Amount / How Long:Ocular HistoryDo 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 HistoryName of Medical DoctorLast Medical ExamDo you take medication?NoYesProvide ListPlease list medications:MedicationReason Do you have any allergies to medications?*YesNoPlease list name of the medication and reaction:MedicationReaction List all major injuries, surgeries and/or hospitalizations.Are you pregnant?YesNoAre you nursing?YesNoReview of SystemsPlease 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 HistoryList the family member(s) that has/had the following: (Ex. Mother, Grandparent, etc)Heart DiseaseMacular DegenerationHigh Blood PressureLazy Eye / AmblyopiaDiabetesEye Turn / StrabismusCancerNystagmusThyroid DiseaseRetinal Detachment / DiseaseCataractArthritisGlaucomaLupus