Vision Source Alamo Heights
Secure Form
New Patient Form
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General Information
Name
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First
Last
Address
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Street Address
Address Line 2
City
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Texas
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Vermont
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
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Mobile / Cell Phone
OK to contact via Text Message?
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Email
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Preferred Contact Method
Primary Phone
Mobile Phone
Email
Date of Birth
Gender
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Male
Female
Other
Marital Status
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Single
Married
Divorced
Legally Separated
Widowed
Race, Ethnicity
Select One
Caucasian
African American/Black
Hispanic/Latino
Asian
Middle Eastern
Pacific Islander
Native American/Alaskan
Other
Referred By
Did anyone refer you to our practice?
Insurance Information
Last Four Digits of Social Security Number
Vision Insurance
Vision Insurance Member Name
Vision Insurance Member ID#
Vision Insurance Member Date of Birth
Medical Insurance Provider
Medical Insurance ID#
Medical Insurance Policy# / Group ID#
Medical Insurance Member Date of Birth
Medical Insurance Member Employer
Your Relationship to Medical Insurance Member
Spouse
Child
Exam History
Last Eye Exam
When was your last eye exam?
Currently Wear Glasses?
Yes
No
Currently Wear Contacts?
Yes
No
Current Contacts Brand
Current Contacts Prescription
Reason for your Visit?
Optical & Medical History
Have you experienced, or been treated for, any of the following? Check all that apply.
Eye Conditions & Disorders
Cataracts
Crossed Eye
Glaucoma
LASIK or RK
Lazy Eye
Macular Degeneration
Retinal Detachment
Blurry Vision (near or far)
Burning
Discharge
Double Vision
Dryness
Excess Tearing/Watering
Eye Infection
Eye Pain or Soreness
Floaters or Spots
Halos
Headaches
Itching
Light Flashes
Light Sensitivity
Redness
Sandy or Gritty Feeling
Medical Conditions
AIDS/HIV
Allergies
Arthritis
Asthma
Blood/Lymph Disorder
Cancer
Diabetes
Ears, Nose, Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction
Family History
Has any of your family members experienced, or been treated for, any of the following? Check all that apply.
Arthritis
Amblyopia
Stroke
Glaucoma
Thyroid Disease
High Blood Pressure
Diabetes
Cancer
Lupus
Kidney Disease
Macular Degeneration
Retinal Detachment
Crossed Eyes
Cataract
Blindness
Medications & Vitals
Current Medications
Medication Drug Allergies
Are you pregnant or nursing?
Yes
No
Do you smoke?
Yes
No
Have you ever smoked?
Yes
No
Phone
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