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10120 S. Eastern Ave., Suite 165

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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 » Previous Patient, Adult Form

Previous Patient, Adult Form

WELCOME TO ENVISION EYECARE
We appreciate you choosing us for your professional eye care.
Today's Date*
Name*
Prefix First Middle Last
Nickname
Marital Status
Date of Birth*
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Preferred Phone Number
Email*
Have we taken care of your family members?*
- Yes
- No
Whom?
Medical Insurance
Vision Insurance
What is the Reason(s) for your Visit?
Are you having vision problems without glasses?
- Yes, distance
- Yes, computer
- Yes, near
- No
Glasses
Do you wear glasses?*
- Yes
- No
If yes, please answer additional questions.
Are you having vision problems with glasses?
- Yes, distance
- Yes, computer
- Yes, near
- No
Are you interested in getting new glasses?*
- Yes
- If my prescription changes
- No
Do your glasses have an anti-glare lenses?*
- Yes
- No
Do you have prescription sunglasses?*
- Yes
- No
Contact Lenses
Do you wear contact lenses?*
- Yes
- No
If no, do you want to try them today?*
- Yes
- No
Are you interested in colored contacts?
- Yes
Refractive Surgery
Are you interested in laser surgery?
- Yes
Ocular History
Please select all that apply.
- Cataracts
- Macular Degeneration
- Glaucoma
- Dry Eye/ Burning/ Pain
- Eye Infection
- Allergies
- Lazy Eye/ Eye Turn
- Floaters
- Flashes
- Retinal Detachment
- Redness
- Itching
- Light Sensitivity
- Eyestrain
- Watery Eyes/ Discharge
- Poor Night Vision/ Glare
- Double Vision
- Surgery
- Injury
- Droopy Eyelid
- Other
Please explain:
Activities
Employer
Occupation
Computer hours per day?
Hobbies?
Medical Information
Name of Medical Doctor
Last Medical Exam
Medications:*
- No Medications
- No Changes
- Will Provide List
- Yes
Please list all current medications:
Allergies:*
- No Know Allergies
- Yes
Please list all known allergies:
Review of Systems
Please select all that apply and fill in the blank box for Other.
Any changes to your Medical History since last visit?*
- Yes
- No
If yes is selected, please complete the below section.
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
- Headaches
- Other
Please Explain Other:
Psychiatric
- Depression
- ADHD
- Anxiety
- Bipolar
- Other
Please Explain Other:
Cardiovascular
- High Blood Pressure
- Stroke
- Heart Disease
- 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
- Arthritis
- Fibromyalgia
- Ankylosing Spondylitis
- 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
- Other
Please Explain Other:
Hematologic/Lymphatic
- Anemia
- Blood Loss
- Ulcer
- High Cholesterol
- Other
Please Explain Other:
Allergic/Immunologic
- Rheumatoid Arthritis
- Lupus
- Sjogren's
- HIV
- Gonorrhea
- Hepatitis
- Syphilis
- Other
Please Explain Other:
Are you pregnant?*
- Yes
- No
- Maybe
Are you nursing?*
- Yes
- No

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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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