Nevada Vision Group Patient History Questionnaire
Please complete all fields. Thank you.
Today's Date
-
Month
-
Day
Year
Date
Name
First Name
Middle Initial
Last Name
What name would you like to be addressed by?
Date of Birth
Birth State
Primary Language
English
Spanish
Other
Race /Ethnicity
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number
Please enter your social security number
Preferred Number
Home
Work
Cell
Occupation
Employer
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Number
Primary and Secondary Vision Insurance
Primary and Secondary Medical Insurance
What is your general health?
What conditions do you have?
Diabetes
High blood pressure
High cholesterol
None of the above
If Diabetic, which is true?
I have Type I
I have Type II
I don't know which type I have
I take Insulin
I do not take Insulin
Year of diabetes diagnosis:
Which system has a problem?
Cardiovascular
Ear/Nose/Throat
Respiratory
Gastrointestinal
Urinary
Muscles/Bones
Skin
Nervous System
Psychiatric
Endocrine (e.g. Thyroid)
Blood/Lymph
Allergic /Immune
Please explain any conditions noted above or any other health problems.
Do you have any allergies to medications?
Yes
No
Which medications?
What is the reaction?
List any current medications and vitamins.
Have you had any operations?
Yes
No
Kind and year of operations.
Have you ever used cigarettes/tobacco and are you currently using?
Alcohol consumption?
Name of primary care doctor
Date of last visit
Date of last tetanus shot?
List any relative with a history of high blood pressure.
List any relative with a history of diabetes.
List any relative with a history of glaucoma.
List any relative with a history of macular degeneration.
List any relative with a history of retinal detachment.
List any relative with a history of cataracts.
When was your last eye exam?
Who was the doctor?
Please list any eye operations you have had and what year they were performed.
Please list any eye injuries you have had and the year they occurred.
Which of the following do you have?
Glaucoma
Macular degeneration
Cataracts
Retinal detachment
Dry eyes
Blurred vision
Do you wear glasses and what are they used for?
Do you wear contact lenses and how often do you wear them?
Please list the brand, power, base curve, and diameter of RIGHT contact
Please list the brand, power, base curve, and diameter of LEFT contact
Submit
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