• Vuity Patient Intake

    This confidential questionnaire takes about four minutes to complete. Your answers will be reviewed by a licensed physician to determine whether Vuity is appropriate for you. A prescription is not guaranteed, and additional information may be requested.
  • Format: (000) 000-0000.
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Your near vision

  • A few questions to better understand your near vision and determine whether your symptoms are consistent with age-related blurry near vision (presbyopia).

  • Do you have difficulty seeing things up close - holding reading material farther away, needing brighter light, or squinting at small print?*
  • Do you currently use reading glasses, bifocals, or progressive lenses for near work?*
  • Has your difficulty seeing things up close developed gradually rather than suddenly?(Sudden changes in vision require prompt in-person medical evaluation.)*
  • Have you had any recent unexplained changes in your distance vision?*

  • Eye health history

  • Certain eye conditions or symptoms may affect whether Vuity is appropriate for you. The following questions will help your physician evaluate your eye health and determine whether additional examination or information is needed.

  • Have you ever been diagnosed with glaucoma, high pressure in your eyes, or narrow drainage angles in your eyes?*
  • Have you ever been diagnosed with iritis or uveitis (inflammation inside the eye)?*
  • Have you ever had a retinal tear, retinal detachment, retinal hole, lattice degeneration, or been told you are at increased risk of retinal detachment? (Risk factors include severe nearsightedness and a family history of retinal detachment.)*
  • Have you ever been diagnosed with macular degeneration, diabetic eye disease, corneal disease, or any other eye condition not already mentioned?*
  • Have you ever had eye surgery, laser treatment, injections into your eye, or a significant eye injury? (Examples include cataract surgery, LASIK, PRK, YAG laser, and retinal injections.)*
  • Do you currently have an eye infection, eye pain, unusual redness, or any other active eye problem?*
  • Have you recently experienced new flashes of light, new floaters, a curtain or shadow in your vision, or sudden vision loss? (These symptoms may indicate a retinal emergency. Seek immediate medical attention rather than waiting for a prescription evaluation.)*
  • Do you wear contact lenses? (If so, remove them before using Vuity and wait at least 10 minutes before putting them back in.)*
  • Do you regularly drive at night or perform activities requiring clear vision in low light? (Vuity can temporarily cause dim or dark vision.)*

  • Your last eye exam

  • Before starting Vuity, a retinal examination is recommended to check for eye conditions that could increase the risk of a retinal tear or detachment.

  • Have you had a comprehensive eye examination by an optometrist or ophthalmologist within the past 24 months?*
  • At your most recent eye examination, did your eye doctor examine your retina (the back of your eye)? This may have involved dilating drops or retinal photography.*
  • At your most recent eye examination, were you told about any abnormal findings or advised to return for additional testing or treatment of an eye problem?*

  • General medical history

  • Certain medical conditions may affect whether Vuity is appropriate for you. The following questions help us make sure this medication is a safe choice.

  • Do you have a history of significant heart disease, an unusually slow heart rate, low blood pressure, or unexplained fainting?*
  • Do you have severe asthma, COPD, or another seroius breathing condition?*
  • Are you pregnant, planning pregnancy, or breastfeeding?*

  • Medications and allergies

  • Please tell us about any medications, eye drops, or allergies so we can make sure Vuity is appropriate for you.

  • Are you currently taking any prescription medications?*
  • Do you currently use any prescription or over-the-counter eye drops, including glaucoma medications or other eye drops for near vision? (If you use more than one eye medication, they must be given at least 5 minutes apart.)*
  • Have you ever had an allergic reaction to pilocarpine, benzalkonium chloride, or any other eye drop medication or ingredient?*
  • Have you previously used Vuity, Qlosi, Vizz, or any other pupil-constricting eye drops and experienced side effects?*

  • Review and consent

  • Your answers will be reviewed by a physician to determine whether Vuity is appropriate for you. Additional information may be requested before a prescription decision is made.

  • Consent Statements*

  • After submitting this form, you will be directed to Push Health to complete a quick, free registration. Registration is required to securely process payment and transmit your prescription to the pharmacy if treatment is approved.

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