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Contact Us
Eye Doctors
Professional Services
Optical Services
Contact Lenses
- Specialty Contacts
Insurance Info

Contact Us
Eye Doctors
Professional Services
Optical Services
Contact Lenses
- Specialty Contacts
Insurance Info

Contact Us
Eye Doctors
Professional Services
Optical Services
Contact Lenses
- Specialty Contacts
Insurance Info

Home » Contact Us » Patient Information Form

Patient Information Form

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.

Patient Name*
Salutation First Middle Last Suffix
Date of Birth*
Month
Day
Year
Age*
Drivers License Number
Issuing State
Expires On
Month
Day
Year
Address*
Street Address Apartment/Suite City State Zip
Contact's Home Phone*
Contact's Mobile Phone*
Contact's Email*
Patient Occupation
Patient Employer
Work Phone
Last 4-digits of Social Security #
Primary Insured Social Security # (Last 4-digits only)
Is this your first visit to our office?*
- Yes
- No
If yes, please tell us who referred you:
Please tell us the reason(s) for your upcoming visit:
(Check all that apply)
- Exam
- Glasses
- Contacts
- Eye Infection or Injury
- Laser Vision Consultation
- Medical Problem
If other, please explain:
Are you planning to get new glasses on this visit?
- Yes
- No
- If neccessary
If you participate in any sports list them here:
Insurance Information
Medical Insurance Company
Medical Policy #
Medical Group #
Medicare #
Vision Insurance Company
Vision Policy #
Vision Group #
Medical History
To help our office better serve your specific needs, please check all that apply. Please leave boxes unchecked for a NO answer.
Eye History
- Headaches
- Glare
- Light Sensitivity
- Tired Eyes
- Eye Infection
- Excess Tearing/Watering
- Redness
- Drooping Eyelid
- Sandy or Gritty Feeling
- Itching
- Crossed Eyes
- Blurred Vision Distance
- Dryness
- Floaters or Spots
- Distorted Vision (halos)
- Burning
- Loss of Side Vision
- Foreign Body Sensation
- Loss of Vision
- Macular Degeneration
- Retinal Detachment
- Glaucoma
- Color Blindness
- Blindness
- Diabetic Retinopathy
- Amblyopia(lazy eye)
- Eye Pain or Soreness
- Fluctuating Vision
- Double Vision
- Blurred Vision Near
- Mucous Discharge
- Cataract(s)
- Other
General Health Condition
- Kidney
- Fever
- Muscles, Bones, Joints
- Ears, Nose, Throat
- Allergic
- Respiratory (Asthma)
- Neurological
- Skin
- Psychiatric
- Joint Pain
- Endocrine
- Cardiovascular Disease
- Bleeding Problems
- Anemia
- Heart Disease
- Diabetes
- Genitals/Kidney/Bladder
- Cancer
- Pregnant or Nursing
- Sinus Congestion
- Runny Nose
- Smoke Cigarettes
- Post-Nasal Drip
- Chronic Cough
- Consume Alcohol
- Lupus
- Stroke
- High Blood Pressure
- Other System
- Thyroid Disease
- Dry Throat/ Mouth
- Chronic Bronchitis
- Emphysema
- Rheumatoid Arthritis
- AIDS/HIV
- Blood/Lymph
- Gastrointestinal
- Weight Loss
Please provide your family doctor's name, address and contact information:
Family History
- Stroke
- Arthritis
- Macular Degeneration
- Amblyopia (Lazy Eye)
- Cancer
- Retinal Detachment
- Glaucoma
- Lupus
- Crossed Eyes
- High Blood Pressure
- Diabetes
- Cataract(s)
- Color Blindness
- Other
- Blindness
- Thyroid Disease
- Kidney Disease
- Heart Disease
Currently taking medication(s) - prescription and/or over the counter
Medication
Reason
Medication
Reason
Medication
Reason
Medication
Reason
Medication
Reason
If you take additional medications, please list them here:
Do you have any drug allergies?*
- Yes
- No
If yes, please list the medication(s):

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Valley Vision Clinic

Phone: (509) 529-2020
Text: 509-529-2020
Fax: 509-505-6284
Email: info@valleyvisionclinic.com
(Do not send personal health information by email.)

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Call: 509-565-8820

Valley Vision Clinic - Located at 22 W Main St., Walla Walla, WA 99362. Phone: (509) 529-2020. https://www.valleyvisionclinic.com

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