Previous Patient, Adult Form WELCOME TO ENVISION EYECAREWe appreciate you choosing us for your 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 Status--Please Select--SingleMarriedWidowedDivorcedDate 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 PhonePreferred Phone Number--Please Select--HomeCellEmail* Have we taken care of your family members?*YesNoWhom?Medical InsuranceVision InsuranceWhat is the Reason(s) for your Visit?Are you having vision problems without glasses? Yes, distance Yes, computer Yes, near No GlassesDo you wear glasses?*YesNoIf 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?*YesIf my prescription changesNoDo your glasses have an anti-glare lenses?*YesNoDo you have prescription sunglasses?*YesNoContact LensesDo you wear contact lenses?*YesNoIf no, do you want to try them today?*YesNoAre you interested in colored contacts?YesRefractive SurgeryAre you interested in laser surgery?YesOcular HistoryPlease 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:ActivitiesEmployerOccupationComputer hours per day?Hobbies?Medical InformationName of Medical DoctorLast Medical ExamMedications:*No MedicationsNo ChangesWill Provide ListYesPlease list all current medications: Allergies:*No Know AllergiesYesPlease list all known allergies: Review of SystemsPlease select all that apply and fill in the blank box for Other.Any changes to your Medical History since last visit?*YesNoIf 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?*YesNoMaybeAre you nursing?*YesNo