Uinta Eye and Vision

Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information


TitleFirstMILastSuffixPreferred Name
Mailing Address:
 
City:
State:    Zip Code:
  
Cell Phone:
Home Phone:
Other Phone:
Email:
Preferred Contact:
SSN:
Birthday:
Sex:
Marital Status:

Patient History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text.

VISUAL HISTORY

Reason for Today's Visit:
Additional Concerns:
Last Eye Exam Date:
I Currently Wear Glasses:  Full-Time Part-Time
     If part-time, how often/when?  
I Currently Wear Contacts: Full-Time Part-Time
     If part-time, how often/when?  
Contact Lens Wearers:   
       Are your lenses comfortable? Yes No  
       Current Brand     
       Solution used:   
       How often do you replace your contacts?   
       How old is your current pair?   
If you are no longer wearing contact lenses, why did you stop?

Do you have history of the following?
Condition Yes No Describe
Blindness
Eye Turn (Strabismus)
Keratoconus
Cataracts
Retinal Detachment
Color Blindness
Lazy Eye (Amblyopia)
Glaucoma
Macular Degeneration
Other Eye Disease


Are you currently experiencing any of the following?
Condition Yes No Describe
Headaches
Blurred Distance Vision
Blurred Near Vision
Double Vision
"Hurting" or "Tired" Eyes
Halos Around Lights
Light Sensitivity
Frequent Styes
Eye Infection
Mucous Discharge
Frequently Red Eyes
Itching Eyes
Burning Eyes
Watering Eyes
Dry Eyes
Sandy or Gritty Eyes
Flashing Lights
Floaters
Ptosis (Drooping Eyelids)
Loss of Side Vision


Describe any eye injuries or surgeries with dates:
List any general / body surgeries with dates:


How many hours a day do you use a computer, tablet, or phone?   
Describe any visual symptoms from screen use:   

MEDICAL HISTORY

Primary Care Physician's Name:   
      Last Visit Date:  
Preferred Pharmacy:  
 
List all medications you are currently taking (Including any OTC / vitamins):
List any medications you are allergic to:
Please list all eye drops you use (OTC and Prescription):


Are you Pregnant or Nursing? Yes No      If Yes, What is the Due/Birth Date?

Do you have, or ever had, any CHRONIC problems in the following areas?
Condition Yes No Describe
Ears, Nose, Throat
Cardiovascular (High BP, Heart, Vessels)
Respiratory (Asthma, Sleep Apnea, etc)
Gastrointestinal (Reflux, Diarrhea, etc)
Genital, Kidney, Bladder
Muscles, Bones, Joints (Arthritis, etc)
Skin (Acne, Warts, Skin Cancer, etc)
Neurological (Migraines, MS, Seizures, etc)
Psychiatric (Anxiety, Depression, Insomnia)
Endocrine (Diabetes, Thyroid, etc)
Blood / Lymph (Cholesterol, Anemia)
Allergic / Immunologic (Allergies, RA, etc)
Other Condition not Listed

Height: Feet    Inches      Weight: Pounds

If you are diabetic, or pre-diabetic, what was your last HbA1c?:

Any history of the following in any Family Members (Parents, Grandparents, Siblings)?
Condition Yes No Relationship To Patient
Poor Vision
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment / Disease
Color Blindness
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Other Inherited Disease
       

SOCIAL HISTORY
Smoking Status   
How often do you consume alcohol:   


Preferred Language   
Race   
Ethnicity   


Employment Status:   
Occupation / Grade:         Employer / School:   
Hobbies / Interests?       


For New Patients:
  Who may we thank for referring you to our clinic?   
  If not referred, how did you hear about Uinta Eye and Vision?   

Submit Form

                                                                                                                                                                                     Version 04/19/2022