VanVision Eyecare Center

VanVision Eyecare Centeradmin2019-12-17T18:47:04+00:00

VanVision Eyecare Center

Basic Information
To 'Submit' form, all required fields in this section must be filled out.
Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Marital Status*
SSN Last 4*
Please enter a number from 0000 to 9999.
Address*
Street Address City State ZIP Code
Employment Status
Occupation
Allow Messaging
- Home
- Text
- Email
Home Phone
Cell Phone
Email
Other Contact Info
Person responsible for charges
Relationship to Patient
Phone
Emergency contact
Emergency contact relationship
Phone
Visit Information
Last eye exam date
MM slash DD slash YYYY
First Visit
- Yes
- No
Reason for current visit
Referred by
Eye Health
Check all that apply
- Amblyopia
- Burning Eyes
- Drooping Eyelid
- Eye Turn
- Foreign Body Sensation
- Headaches
- Loss of Vision - Central
- Redness
- Blurred Vision - Far
- Cataracts
- Dry Eyes
- Floaters/Spots
- Glaucoma
- Itchy Feeling
- Loss of Vision - Side
- Retinal Detachment
- Blurred Vision - Near
- Double/Distorted Vision
- Eye Surgeries
- Fluctuating Vision
- Glare/Light Sensitivity
- Infection of eye/lid
- Mucus/Discharge
- Tearing/Watery Eyes
General Health
Check all that apply
- Allergies/Hay Fever
- Cancer
- Chronic Cough
- Gastrointestinal Problems
- Kidney Disease
- Thyroid/Endocrine Disease
- Asthma/Respiratory
- Cardiovascular/High BP
- Diabetes
- Heart Attack/Strokes
- Psychiatric Depression
- Skin Disorders
- Blood Disorders
- Chronic Bronchitis
- Emphysema
- Headaches/Migraines
- Rheumatoid Arthritis
- Weight Loss/Gain
Do you smoke tobacco products?
- Yes, I smoke everyday
- Yes, I smoke occasionally
- No, I'm a former smoker
- No, I've never been a smoker
Family History - Blood Relatives
Check all that apply
- Amblyopia
- Cataracts
- Glaucoma
- Retinal Detachment
- Blurred Vision - Far
- Dry Eyes
- Loss of Vision - Central
- Blurred Vision - Near
- Eye Turn
- Loss of Vision - Side
Physician / General Practitioner
Physician Name
Phone
Last Medical Exam Date
MM slash DD slash YYYY
Medications
Enter all medications taken, and for which condition each is taken
Medication Condition
Medication Condition
Medication Condition
Medication Condition
Medication Condition
Medication Condition
Medication Condition
Medication Condition
Allergies
Enter all medications or substances to which the patient is allergic
Please answer the following questions
Are you pregnant or nursing?
- Yes
- No
Do you have trouble driving at night?
- Yes
- No
Do you wear glasses?
- Yes
- No
Do you wear contacts?
- Yes
- No
Do you experience blur, headaches, or eyestrain with computer use?
- Yes
- No
Are you interested in laser (refractive) surgery to correct your vision?
- Yes
- No
Vision Insurance Information
Insurance Company
ID Number
Group Number
Patient's relationship to insured
- Self
- Spouse
- Child
- Other
Primary Insured's Sex
- Male
- Female
Name of the Insured
Insured's Phone Number
Insured's Date of Birth
MM slash DD slash YYYY
Other Insurance Information
Insurance Company
ID Number
Group Number
Patient's relationship to insured
- Self
- Spouse
- Child
- Other
2nd Insured's Sex
- Male
- Female
Name of the Insured
Insured's Phone Number
Insured's Date of Birth
MM slash DD slash YYYY
Additional Comments
Is there anything else we should know? Let us know below.

Medication	Condition

Medication	Condition

Medication	Condition

Medication	Condition

VanVision Eyecare Center

Basic Information

Other Contact Info

Visit Information

Eye Health

General Health

Family History - Blood Relatives

Physician / General Practitioner

Medications

Allergies

Please answer the following questions

Vision Insurance Information

Other Insurance Information

Additional Comments