16020 North 35th Avenue
Phoenix, AZ 85053
OUR OFFICE HOURS
MON - THUR - 9:00AM - 6:00PM
TUE - 9:00AM - 6:30PM
FRI - 8:00AM - 2:30PM
-- Choose GenderMaleFemale
Are you interested in: (Please check all that apply)
GlassesContact lensesTherapeutic/Vision Therapy
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Do you presently wear glasses? YesNo
Do you presently wear contacts? YesNo
Have you ever worn contacts? YesNo
List any current medications and the reasons for taking them.
(if not known, please check which types):
Do you suffer from any of the following (Please select one)
with glassescontacts if wornwithout correction
Distance Vision Blurry
Middle Distance Blur
Near Vision Blur
Pain In or Around Eyes
Problems with Focusing
Eye Strain / Fatigue
Seeing Spots or Lines
Dilated at that exam? YesNo
High Blood Pressure
Amblyopia (lazy eye)
Skin Disease (e.g. eczema)
Do you smoke?
If yes, how often?
If no, have you ever smoked?
Do you use recreational drugs?
Do you drink alcohol?
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Dilated exams provide the doctor with a more comprehensive view of the retina (back layer of the eye) and are essential in the early detection and prevention of many eye diseases. Dr. Gong strongly recommends dilation. Eye drops are required and your near vision will remain blurred and light sensitive for several hours. When dilated, we advise you to exert caution when driving.
Please indicate if you wish to have the dilation test done today:*
YesNoRescheduleDiscuss with doctor
A retinal photo gives Dr. Gong a detailed picture of the back of your eyes. This can help detect conditions such as glaucoma, diabetes, hypertension, and retinal detachment, among many others. These photos will be saved in your file to compare to over the years.
Please indicate if you wish to have Retinal Photos done today:*
YesNoDiscuss with doctor
I was referred by
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Payment is expected in full when services are rendered. Eyeglasses and contact lenses must be paid for in full. Who is responsible for your bill (those charges not covered by insurance)?
Non-Insulin Dependent DiabetesInsulin Dependent DiabetesThyroid DysfunctionHormonal DysfunctionOtherNone
FibromyalgiaMuscular DystrophyOsteoarthritisAnkylosing SpondylitisOtherNone
Heart DiseaseHypertension (High Blood Pressure)StrokeVascular DiseaseOtherNone
Drug AllergyEnvironmental AllergyRheumatold ArthritisLupusOtherNone
STD, Viral Herpetic, ChlamydiaOtherNone
GlaucomaCataractsMacular DegenerationSurgeryInflammartory DisordersBlurred VisionDouble VisionOtherNone
AnemiaLarge Volume Blood LossLeukemiaOtherNone
Upper Respiratory Track InfectoinEar AcheRunny NoseSore ThrosatRinging/TinnitisOtherNone
Developmental DisabilityWeight LossFeverFatigueTraumaOtherNone
Purpose of Today's Visit. (Please check all that apply):GlassesContact LensesTherapeutic/vision TherapyAnnual ExamOther