998 Plaza Dr., Grass Valley, CA 95945

Call Us: (530) 273-6000

Grass Valley Eyecare Optometric Inc.

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New Patient

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Your Name

If Child, Parent or Guardian Name

Date of Birth

Social Security Number

Mailing Address

City

State

Zip

Phone Number (Home)

Work or Cell

E-mail

Occupation

Hobbies

Insurance: Vision

Medical, Primary

Medical, Secondary

Is either your primary or secondary insurance an HMO?

Yes

No

Free Text

Our office is unable to bill any HMO plan

Primary Care Physician

Chief Complaint (Reason for today's exam)

Do you have difficulty with glare or poor vision driving at night?

Yes

No

Do you work on a computer?

Yes

No

Do you wear contact lenses?

Yes

No

Are you interested in wearing contact lenses?

Yes

No

Are you interested in refractive laser surgery

Yes

No

Free Text

Eye History

Date of your last eye exam

Here?

Yes

No

If no, where?

Free Text

Do you have or have you had:

Eye injuries?

Yes

No

If yes, specify

Eye Surgeries?

Yes

No

If yes, specify

Eye diseases?

Yes

No

If yes, specify

Cataracts

Yes

No

Floaters

Yes

No

Flashes of light?

Yes

No

Light Sensitivity?

Yes

No

Itchy eyes?

Yes

No

Burning in eyes?

Yes

No

Dry eyes?

Yes

No

Redness?

Yes

No

Pain in eyes?

Yes

No

Free Text

Family History

Glaucoma?

Yes

No

If yes, how related?

Blindness?

Yes

No

If yes, how related?

High Blood Pressure?

Yes

No

If yes, how related?

Diabetes?

Yes

No

If yes, how related?

Macular Degeneration

Yes

No

If yes, how related?

Free Text

General Health

Is your general health good?

Yes

No

Free Text

Do you have a history of:

Problems with ears, nose, mouth, throat?

Yes

No

If yes, describe below

Cardiovascular issues?

Yes

No

If yes, describe below

High Blood Pressure?

Yes

No

If yes, describe below

Respiratory Problems?

Yes

No

If yes, describe below

Gastrointestinal issues?

Yes

No

If yes, describe below

Genitourinary issues?

Yes

No

If yes, describe below

Kidney problems?

Yes

No

If yes, describe below

Musculoskeletal issues?

Yes

No

If yes, describe below

Arthritis? Osteo/Rheumatoid?

Yes

No

If yes, describe below

Integumentary / Skin conditions?

Yes

No

If yes, describe below

Neurological issues?

Yes

No

If yes, describe below

Stroke?

Yes

No

If yes, describe below

Psychiatric concerns?

Yes

No

If yes, describe below

Endocrine, Thyroid / Diabetes?

Yes

No

If yes, describe below

Lymphatic / Hematological?

Yes

No

If yes, describe below

Allergies / Immunological?

Yes

No

If yes, describe below

Do you smoke?

Yes

No

Do you use recreational drugs?

Yes

No

Decline to answer

Do you consume alcohol?

Yes

Yes

If yes

Rare

Social

Frequent

Free Text

Current Medications

(include prescriptions, over the counter, tablets, injections, eye drops, birth control, hormones, antihistamines)

Are you allergic to any medications?

Yes

No

If yes, specify

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

New Patient Form

Contact Us

Your Name

If Child, Parent or Guardian Name

Date of Birth

Social Security Number

Mailing Address

City

State

Zip

Phone Number (Home)

Work or Cell

E-mail

Occupation

Hobbies

Insurance: Vision

Medical, Primary

Medical, Secondary

Is either your primary or secondary insurance an HMO?

Yes

No

Free Text

Our office is unable to bill any HMO plan

Primary Care Physician

Chief Complaint (Reason for today's exam)

Do you have difficulty with glare or poor vision driving at night?

Yes

No

Do you work on a computer?

Yes

No

Do you wear contact lenses?

Yes

No

Are you interested in wearing contact lenses?

Yes

No

Are you interested in refractive laser surgery

Yes

No

Free Text

Eye History

Date of your last eye exam

Here?

Yes

No

If no, where?

Free Text

Do you have or have you had:

Eye injuries?

Yes

No

If yes, specify

Eye Surgeries?

Yes

No

If yes, specify

Eye diseases?

Yes

No

If yes, specify

Cataracts

Yes

No

Floaters

Yes

No

Flashes of light?

Yes

No

Light Sensitivity?

Yes

No

Itchy eyes?

Yes

No

Burning in eyes?

Yes

No

Dry eyes?

Yes

No

Redness?

Yes

No

Pain in eyes?

Yes

No

Free Text

Family History

Glaucoma?

Yes

No

If yes, how related?

Blindness?

Yes

No

If yes, how related?

High Blood Pressure?

Yes

No

If yes, how related?

Diabetes?

Yes

No

If yes, how related?

Macular Degeneration

Yes

No

If yes, how related?

Free Text

General Health

Is your general health good?

Yes

No

Free Text

Do you have a history of:

Problems with ears, nose, mouth, throat?

Yes

No

If yes, describe below

Cardiovascular issues?

Yes

No

If yes, describe below

High Blood Pressure?

Yes

No

If yes, describe below

Respiratory Problems?

Yes

No

If yes, describe below

Gastrointestinal issues?

Yes

No

If yes, describe below

Genitourinary issues?

Yes

No

If yes, describe below

Kidney problems?

Yes

No

If yes, describe below

Musculoskeletal issues?

Yes

No

If yes, describe below

Arthritis? Osteo/Rheumatoid?

Yes

No

If yes, describe below

Integumentary / Skin conditions?

Yes

No

If yes, describe below

Neurological issues?

Yes

No

If yes, describe below

Stroke?

Yes

No

If yes, describe below

Psychiatric concerns?

Yes

No

If yes, describe below

Endocrine, Thyroid / Diabetes?

Yes

No

If yes, describe below

Lymphatic / Hematological?

Yes

No

If yes, describe below

Allergies / Immunological?

Yes

No

If yes, describe below

Do you smoke?

Yes

No

Do you use recreational drugs?

Yes

No

Decline to answer

Do you consume alcohol?

Yes

Yes

If yes

Rare

Social

Frequent

Free Text

Current Medications

(include prescriptions, over the counter, tablets, injections, eye drops, birth control, hormones, antihistamines)

Are you allergic to any medications?

Yes

No

If yes, specify

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

New Patient Form

Contact Us

Your Name

If Child, Parent or Guardian Name

Date of Birth

Mailing Address

City

State

Zip

Phone Number (Home)

Work or Cell

E-mail

Occupation

Hobbies

Insurance: Vision

Medical, Primary

Medical, Secondary

Is either your primary or secondary insurance an HMO?

Yes

No

Free Text

Our office is unable to bill any HMO plan

Primary Care Physician

Chief Complaint (Reason for today's exam)

Do you have difficulty with glare or poor vision driving at night?

Yes

No

Do you work on a computer?

Yes

No

Do you wear contact lenses?

Yes

No

Are you interested in wearing contact lenses?

Yes

No

Are you interested in refractive laser surgery

Yes

No

Free Text

Eye History

Date of your last eye exam

Here?

Yes

No

If no, where?

Free Text

Do you have or have you had:

Eye injuries?

Yes

No

If yes, specify

Eye Surgeries?

Yes

No

If yes, specify

Eye diseases?

Yes

No

If yes, specify

Cataracts

Yes

No

Floaters

Yes

No

Flashes of light?

Yes

No

Light Sensitivity?

Yes

No

Itchy eyes?

Yes

No

Burning in eyes?

Yes

No

Dry eyes?

Yes

No

Redness?

Yes

No

Pain in eyes?

Yes

No

Free Text

Family History

Glaucoma?

Yes

No

If yes, how related?

Blindness?

Yes

No

If yes, how related?

High Blood Pressure?

Yes

No

If yes, how related?

Diabetes?

Yes

No

If yes, how related?

Macular Degeneration

Yes

No

If yes, how related?

Free Text

General Health

Is your general health good?

Yes

No

Free Text

Do you have a history of:

Problems with ears, nose, mouth, throat?

Yes

No

If yes, describe below

Cardiovascular issues?

Yes

No

If yes, describe below

High Blood Pressure?

Yes

No

If yes, describe below

Respiratory Problems?

Yes

No

If yes, describe below

Gastrointestinal issues?

Yes

No

If yes, describe below

Genitourinary issues?

Yes

No

If yes, describe below

Kidney problems?

Yes

No

If yes, describe below

Musculoskeletal issues?

Yes

No

If yes, describe below

Arthritis? Osteo/Rheumatoid?

Yes

No

If yes, describe below

Integumentary / Skin conditions?

Yes

No

If yes, describe below

Neurological issues?

Yes

No

If yes, describe below

Stroke?

Yes

No

If yes, describe below

Psychiatric concerns?

Yes

No

If yes, describe below

Endocrine, Thyroid / Diabetes?

Yes

No

If yes, describe below

Lymphatic / Hematological?

Yes

No

If yes, describe below

Allergies / Immunological?

Yes

No

If yes, describe below

Do you smoke?

Yes

No

Do you use recreational drugs?

Yes

No

Decline to answer

Do you consume alcohol?

Yes

No

If yes

Rare

Social

Frequent

Free Text

Current Medications

(include prescriptions, over the counter, tablets, injections, eye drops, birth control, hormones, antihistamines)

Are you allergic to any medications?

Yes

No

If yes, specify

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Browse our Website

Home
About
Eyecare
Products
Resources
Contact

Contact Information

Address: 998 Plaza Dr., Grass Valley, CA 95945

Phone: (530) 273-6000

Email: gveofficemanager@att.net

Business Hours

Mon, Tue, Thu: 8:30 am - 5:30 pm
Wednesday: 9:00 am - 5:30 pm
Friday: 7:30 am - 4:30 pm
Sat - Sun: Closed

*We close for lunch Monday - Friday from 1:15 pm to 2:30 pm.

Browse our Website

Home
About
Eyecare
Products
Resources
Contact

Contact Information

Phone: (530) 273-6000

Address: 998 Plaza Dr., Grass Valley, CA 95945

Email: gvefrontdesk@att.net

Business Hours

Mon, Tue, Thu: 8:30 am - 5:30 pm
Wednesday: 9:00 am - 5:30 pm
Friday: 7:30 am - 4:30 pm
Sat - Sun: Closed

*We close for lunch Monday - Friday from 1:15 pm to 2:30 pm.

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