You have booked your eye exam Please fill in and submit the patient history form below at least 24 hours prior to your eye exam Name* First Last Address* Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email COVID-19 Screening. Have you in the past 14 days:* Traveled outside of Canada Experienced any COVID-19 symptoms such as fever, cough, or shortness of breath Been in close contact with a person who tested positive for COVID-19 None of the above Personal Health Number* Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Family Doctor*enter n/a if you don't have a family doctor When was your last Eye Exam?* What is the reason for your visit?* What is your occupation? What are your hobbies? Personal Medical History*Check all that apply to you. Diabetes High Blood Pressure Thyroid Disease Multiple Sclerosis Migraines Double Vision Difficulty Judging Depth Itchy Eyes Dry Eyes Cataracts Glaucoma Macular Degeneration None of the Above Do you have any other medical conditions?*Please list or indicate "none"Have you had any other eye health problems, injuries, and/or surgery?*Please describe or indicate "none"Please list any medications you are currently taking.Do you have any environmental or medication allergies?Family Medical HistoryPlease indicate your family history of eye health problems or medical conditions.Do you smoke? Yes No, but I did No How long did you smoke? When did you quit? Check all types of glasses you own* Distance Glasses Reading Glasses Progressives (no line bifocal) Bifocal/Trifocal (with the line) Computer/Task Glasses Prescription Sunglasses Non-prescription Sunglasses Back-up Glasses None Do you wear contact lenses?* Yes No What type of lenses do you wearMonthly Disposable2 Week DisposableDaily DisposableRGPHow often do you wear your contact lenses?eg. How many days/week. How many hours/day What contact lens solution do you use? Is there anything else you would like the Optometrist to know?CommentsThis field is for validation purposes and should be left unchanged. Δ
