Alpine Vision Clinic On-Line Welcome Form

 

Please take a few minutes to complete this on-line Patient Welcome Form before you visit our office. Once you fill in the information, click on the "Submit" button to e-mail it to our office. After you click on the submit button you may be prompted to click on a back button if you have not filled in all of the required fields. If this occurs after clicking on the submit button DO NOT click on the back button box as this may erase all of the information you have previously entered depending on the type of browser you are using. Please use the back arrow button on the upper left tool bar of your screen to go back into the welcome form to add information. If you are unable to submit the on-line welcome form to our office for any reason please print a copy and bring it with you to your next appointment. This on-line form is encrypted and password protected to ensure the privacy of your personal information.

 

Complete Your Personal Information:

Salutation:

Mr. Mrs. Ms. Dr. Miss. Master Rev.

First Name:*

     

MI:

     

Last Name:*

     

 

Preferred Name:

     

 

Address:

     

City:

     

State:

     

Zip:

     

Home Phone:

     

Work Phone:

     

Cell Phone:

     

Work Phone Ext.:

     

Email Address:*

     

Date of Birth: (MM/DD/YYYY)*

     

I give permission to the Alpine Vision Clinic to use my email address for clinic communication:

 

Yes No

 

Patient's Gender:

 

Male Female

Spouse/Parent Name:

     

Guardian:

     

Emergency Contact Name:

     

Emergency Contact Phone Number:

     

 

 

 

 

 

How did you learn about the Alpine Vision Clinic?

Phone Book

School

Ad

Previous Patient

 

Insurance Listing

Drive By

Other

Doctor

 

 

 

Referred By:

     

 

 

 

Race:

American Indian or Alaska Native

Asian

Caucasian

 

Black or African American

White

Not Disclosed

 

Native American

Refuse to Specify

 

Native Hawaiian or Other Pacific Islander

 

 

Other Race      

 

 

 

 

 

Height:

ft

     

ft in

 

In

     

 

cm/m

     

cm m

Weight:

     

lbs kg

 

 

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown

Language Preferences:

English Spanish French Italian Russian Portuguese

Complete Your Primary Care Physician:

First Name:

     

MI:

     

Last Name:

     

 

Clinic Name:

     

 

Address:

     

City:

     

State:

     

Zip:

     

Phone Number:

     

 

 

Complete Your Referring Physician:

First Name:

     

MI:

     

Last Name:

     

 

Clinic Name:

     

 

Address:

     

City:

     

State:

     

Zip:

     

Phone Number:

     

 

Complete Your Health History:

 

What is the main reason for your current visit to our office?

     

 

 

 

What was the date of your last general health exam?

     

 

 

Please enter past illnesses or injuries:

     

     

 

Please enter past surgeries?

     

     

 

Please list any medicines that have caused adverse reactions or sensitivities:

     

 

Please list any specific nonmedical allergies:

     

 

Please bring all of your prescribed medications to your appointment.

 

Please bring all supplements you use to your appointment.

 

Please bring all eye drops you use to your appointment.

 

Physically bring the above items so we will know exactly what you are using.

 

Complete Your General Health Condition Information:

Recent Fever:

Yes

No

Muscles/Bones/Joints (arthritis, etc.)

Yes

No

Recent Weight Loss:

Yes

No

Skin (rash, itching, cancer):

Yes

No

Cancer:

Yes

No

Neurological (Parkinsons, multiple sclerosis, etc.):

Yes

No

Ears/Nose/Throat/Mouth:

Yes

No

Psychiatric (anxiety, bipolar, depression, etc.):

Yes

No

Cardiovascular conditions
(high blood pressure, heart disease, etc.):

Yes

No

Endocrine (thyroid, diabetes, etc.):

Yes

No

Respiratory (asthma, emphysema, etc.):

Yes

No

Blood/Lymph (anemia, cholesterol, etc.)

Yes

No

Gastrointestinal:

Yes

No

Allergies/Immunologic (seasonal allergies, lupus, etc.):

Yes

No

Genital/Kidney/Bladder:

Yes

No

 

 

 

Are you currently?

Pregnant Nursing

 

Complete Your Family History:

Amblyopia (Lazy Eye):

Yes

No

Cancer:

Yes

No

Blindness:

Yes

No

Diabetes:

Yes

No

Cataract(s):

Yes

No

Heart Disease:

Yes

No

Color Deficiency/Blindness:

Yes

No

High Blood Pressure:

Yes

No

Glaucoma:

Yes

No

Kidney Disease:

Yes

No

Macular Degeneration:

Yes

No

Lupus:

Yes

No

Retinal Detachment:

Yes

No

Stroke:

Yes

No

Strabismus (Turned Eye)

Yes

No

Thyroid Disease:

Yes

No

Arthritis:

Yes

No

Other Conditions:

Yes

No

 

Complete Your Eye History:

Glaucoma:

Yes

No

Infection/Pain of Eyelid:

Yes

No

Cataract:

Yes

No

Itching:

Yes

No

Macular Degeneration:

Yes

No

Mucous Discharge:

Yes

No

Retinal Detachment or Tear:

Yes

No

Drooping Eyelid:

Yes

No

Color Deficiency or Blindness:

Yes

No

Redness:

Yes

No

Headaches:

Yes

No

Sandy or Gritty Feeling:

Yes

No

Glare/Light Sensitivity:

Yes

No

Blurry Vision Distance:

Yes

No

Tired Eyes:

Yes

No

Blurry Vision Near:

Yes

No

Amblyopia (Lazy Eye):

Yes

No

Strabismus(Eye Turn or Cross):

Yes

No

Burning:

Yes

No

Distorted Vision or Halos:

Yes

No

Dryness:

Yes

No

Double Vision:

Yes

No

Excess Tearing/Watering:

Yes

No

Floaters or Spots:

Yes

No

Eye Pain or Soreness:

Yes

No

Fluctuating Vision:

Yes

No

Foreign Body Sensation:

Yes

No

Transient or Permanent Loss of Vision:

Yes

No

Loss of Side Vision:

Yes

No

 

 

 

 

Complete Your Spectacle Lens History:

Do you use a computer?

Yes

No

How many hours/day do you use a computer?

     

Distance you work from the computer?

     

Do you drive?

Yes

No

Mileage to work each way?

     

Do you have glare problems?

Yes

No

Do you have visual difficulty when driving?

Yes

No

Do you have problems with night vision?

Yes

No

Do you currently wear glasses?

Yes

No

Since?

     

How do you wear your glasses?

Full Time Part Time Distance Close

Type of glasses currently owned:

Single Vision

Bifocals

Trifocals

Progressive

 

Sports

Safety

Backup

Have you had trouble with glasses in the past?

Yes

No

What kind?

     

Do you wear sunglasses?

Yes

No

Are your sunglasses your current prescription?

Yes

No

Do you have special eyewear needs?

Computer (special prescriptions, special anti-glare tints or coatings)

 

Occupational (mechanics, plumbers, pilots)

 

Safety Glasses (gardening, woodworking, welding)

 

Sports/Hobbies (racquet sports, bicycling, shooting, motorcycle)

Complete Your Contact Lens History:

1. Do you currently wear contact lenses?

Yes No

If no, then go to questions 7 through 9.

2. How long have you worn contacts?

     

 

3. What type and brand of contact lenses

do you wear?

     

 

4. Do you wear your contact lenses while

sleeping?

     

 

5. How many hours/day do you usually

wear your contact lenses?

     

 

6. How many days/week do you usually

wear your contact lenses?

     

 

7. If you are not a current contact lens

wearer, are you interested in trying

contact lenses at this time?

Yes

No

8. Have you ever tried to wear contacts?

Yes

No

9. If yes, what was the reason for

discontinuing use?

     

 

 

Please rate the following on a scale of Excellent, Good, Poor, Terrible, or Not Applicable.

Lens Comfort:

Right

     

Left

     

Distance Vision:

Right

     

Left

     

Near Vision:

Right

     

Left

     

What contact lens cleaner do you use?

     

 

What contact lens conditioner do you use?

     

 

What multipurpose solution do you use?

     

 

 

Complete Your Social History:

Current occupation, retired, or student:

     

Years worked, retired, or school grade?

     

Employer or school name:

     

Do you use nutritional supplements (vitamins etc.)?

Yes

No

 

Do you engage in regular exercise?

Yes

No

 

 

Do you drink alcohol? If yes - how much/often?

No

Occasional

1 per day

 

2-3/day

4+/day

 

 

Do you smoke? If yes - how much/often?

No

Occasional

1/2 pack/day

 

1 pack/day

1+ pack

 

 

 

 

Smoking Status:

Current every day smoker

 

 

Current some day smoker

 

 

Former smoker

 

 

Never smoked

 

 

Smoker, current status unknown

 

Unknown if ever smoked

 

 

 

 

 

Method of Tobacco Intake?

Smoking

Chewing

 

Do you use Illegal Drugs?

Yes

No

 

Please list your hobbies:

     

 

Please bring the following items to your appointment:

All eye glasses

All contact lenses (current contact lenses being worn as well as boxes and/or foil packs with contact lens parameters)

Contact lens case and all current contact lens solutions being used

All eye drops currently being used

All current medications and dosage information (bring the actual bottles of medicine with identifying information in a plastic or paper bag)

Your medical and vision insurance card, coupon, or other identifying insurance information

Photo ID (drivers license, military ID, student ID, etc.)

 

Thank you for your time in completing the on-line welcome form. We will be able to provide you with the best evaluation of your ocular and general health utilizing this information. We look forward to seeing you soon!

 

 


 Print a copy for your records