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Help Us Get To Know You Better Please answer the following questions to assist us in providing you with the most complete overall service as we assess your ocular health, comfort and vision. All information provided is held in the strictest confidence, in compliance with the Health Information Protection Act. Name: ____________________________________________ M: F: DOB: _____/_____/________ Address: __________________________________________________________________________________________ Phone: ______________ Alt. Phone: ______________ ( cell / work ) Email: ___________________________________ Emergency Contact: Name: ________________________ Phone #: _________________________________ Parent/ Guardian (If under 18 years): ____________________________ Relationship to patient: ____________________ Occupation/ Grade (if student): _______________________________ Medical doctor: ________________________________ Previous Optometrist: _________________________________ Are you covered by any government assistance programs? (Family Health, SIP, Supplemental Health) N: Do you have employee optical benefits (Safety Glasses coverage, PVS, Great West, Blue Cross, etc)? N: Do you require a copy of your eyeglass prescription today? N: Y: Reason(s) for your visit today? Contact lenses Diabetic exam SGI required exam First eye exam ever Emergency/ Red eye Physician referral Workplace Safety Glasses needed Current Glasses: None Distance only Reading only Progressive Lenses Bifocal or Trifocal Lenses Computer Lenses Safety glasses none Current Contact Lenses: Do you suffer from any of the following? No Rarely Y: Y: Routine/ complete check-up Broken/ damaged/ lost glasses School or Public Health referral Other: ______________________ None Solution Used: Renu Regular/ Daily wear Optifree Multifocals/ Bifocals B&L Sensitive Eyes Part time wear BioTrue Overnight wear Clear Care 1 Day Disposable SoloCare Rigid Gas Permeable Boston Advance/ Simplicity Other: __________________________________________ Have you ever been diagnosed with any of the following? Daily Blurry vision Glare when driving Sensitivity to light Double vision Floating spots Flashing lights Headaches/ Eyestrain Stinging/ Burning/ Tearing Itchy eyes Frequent styes Please list any eye surgeries you have had: ___________________________________________ ___________________________________________ ___________________________________________ Dry eyes Crohns/ Colitis Cataracts Cancer Glaucoma Rheumatoid Arthritis Macular Degeneration Lupus Iritis/ Uveitis MS Turned/ Lazy Eye Alzheimers/ Dementia Keratoconus Raynaud’s syndrome Eye injuries Migraines Diabetes Sleep Apnea High Blood Pressure Kidney disease Thyroid condition Seizures/ Epilepsy Heart disease Hepatitis Asthma/ COPD HIV + / AIDS Celiac disease MRSA +/ VRE + (Females only) Are you currently pregnant? No Yes No Yes ~~~ OVER ~~~ Please list all Medications (including Over-the-Counter, Herbals, Vitamins, Supplements) that you are taking: None ________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Are you Allergic to any Medications or do you suffer from allergies to Seasonal or Environmental factors? N: Y: If yes, please list: ______________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ________________________ Please list all major surgeries you have undergone (not including your eyes): None __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you smoke cigarettes? N: Y: How many per day? ______________ Are you interested in information or help quitting from Canada’s Smoker’s Helpline? N: Y: Do any of your family members have any of the following conditions? Please check all that apply: Cataracts Glaucoma Blindness Macular Degeneration Iritis/ Uveitis Keratoconus Color vision problem Crossed/ Turned eye Lazy eye (amblyopia) Ocular (eye) cancer Retinal Detachment Diabetes High Blood Pressure Heart condition Stroke Thyroid condition Crohns/ Colitis Lupus Multiple Sclerosis Rheumatoid Arthritis Celiac disease Liver disease Kidney disease Cancer Brain Tumor Sarcoidosis Ankylosing Spondylitis Alzheimers/ Dementia Do you use a Computer for Home or Work? N: Y: Average hours per day? _____________________ Do you use a Cell Phone for Texting and/or email? N: Y: Average hours per day? _____________________ Does your Driver’s License state you MUST wear corrective lenses to drive? N: Y: no license: Hobbies/ Home Activities: Please check all those that apply: Reading (2+ hrs a day) Knit/ crochet Sewing/ quilting/cross-stitch Scrapbooking Musical instruments Gardening Wood or metal working Snowmobiling I would like more information on the following: Sunglasses Anti-Fog coating Transitions Lenses Thinner/ lighter lenses UV protection Progressive lenses Scratch protection Computer lenses Anti-Glare coatings Safety glasses Hunting Swimming Squash/ Badminton Hockey Prescription swim goggles Multiple pairs of glasses Contact lenses Laser eye surgery Children’s Vision/ Exams Cataracts Martial Arts Gymnastics/ Dance Computer/ Video games Other: _________________ Glaucoma testing/ treatment Diabetic eye health Macular Degeneration Nutrition for eye health Dry eye treatment/ support Low Vision Exam/ Aides How did you Previous/ existing patient Yellow Pages Internet hear about us? Word of mouth Advertisement Walked/ drove by Referred by: (name) ________________________________________________________ (so we can say “Thank You”) Thank you for choosing us for your eye care needs Patient signature: _______________________________________________________ Date: _______________ (parent or guardian signature if patient under 18 years of age)
