Welcome to Crystal Vision Center
Select office location for your visit
*
Scranton
South Wilkes-Barre, Carey Ave
Wilkes-Barre Twp Rt 309
Bethlehem
Walnutport
Dallas
Tunkhannock
Patient Health History
Eye Examination
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Appointment (if known)
-
Month
-
Day
Year
Date
Employer
Occupation
Marital Status
Single
Married
Divorced
Last Eye Exam
*
how many years/months ago
Diabetes
*
Self
Family
None
High Blood Pressure
*
Self
Family
None
Thyroid Problems
*
Self
Family
None
Heart Disease
*
Self
Family
None
Asthma
*
Self
Family
None
Cancer
*
Self
Family
None
Glaucoma
*
Self
Family
None
Cataracts
*
Self
Family
None
Retinal Disease
*
Self
Family
None
Eye Surgery
*
Self
Family
None
Eye Injury
*
Yes
No
HIV/AIDS
*
Self
Family
None
Do you see double?
*
Yes
No
Do you get headaches when reading?
*
Yes
No
Have you ever had a dilated eye exam?
*
Yes
No
Not sure
Are you pregnant?
*
Yes
No
List all medications you currently take:
*
List any allergies you may have:
*
Primary Care Physician
Pharmacy
Do you currently wear:
*
Glasses
Contacts Lenses
None
Do you want to wear Contact Lenses?
Yes
No
Are you interested in Sports / Safety Eyewear
Yes
No
Do you have difficulty seeing:
Desk Computer
Laptop Computer
Tablet/IPad
Smart Phone
Are you bothered by:
Glare
Car Head Lights
Night Driving
Indoor Lighting
Sunlight
Is there anything else you want us to know?
Submit
Should be Empty: