Online Welcome Form

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 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 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?

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!

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 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:

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

Lens Comfort:

Distance Vision:

Near Vision: