Valley Vision Optometric Center

Name*

First Middle Initial Last

Birthdate*

Last 4 SSN*

Please enter a number from 0 to 9999.

Email*

Marital Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Business Phone

Name of Parent or Spouse*

First Last

Have we examined other members of your family?*

Yes
No

Occupation

Employer

Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Name of Family Physician*

First Last

How Did You Find Out About Our Office*

What Is Your General Health Status?*

List All Medications You Are Taking*

Pharmacy Name*

Medication Allergies*

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years*

Are You Pregnant?*

Yes
No

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam*

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

Current Eyedrops

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*

Family History (Family History includes your parents, grandparents, siblings, and your children)*

Blindness
Cataract
Glaucoma
Diabetes
High Blood Pressure
Cancer
Thyroid Disease
Macular Degeneration
None of the Above

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient Eye Health*

Amblyopia (lazy eye)
Cataracts
Double Vision
Glaucoma
Retinal Detachment
None of the Above

Patient General Health