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Transcript
9565 Weston Road #100
Vaughan, ON
L4H 3A5
T: 905 303 9775
F: 905 303 9791
E: [email protected]
PATIENT HISTORY FORM Name: _______________________________________________________ Birth date (month/day/year): ______ / ______ / ______
Address: ________________________________________City: ___________________________ Postal Code: __________________
❑ Business # Home phone # ________________ ❑ Cell phone # ________________ E-­‐mail: ___________________________________
How would you like to be contacted? ❑ E-mail ❑ Phone ❑ Text Message
Occupation: ________________________ Who referred you to us?: __________________ Date of last eye exam: ____________ Family Doctor: ___________________________ Are you required to wear glasses or contacts to drive? ❑Yes ❑No ❑No license
Are you allergic to any medications, eye drops, or contact lens solutions? ❑No ❑Yes, list:_____________________________________
YOUR MEDICAL HISTORY ❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
Environment allergy
Arthritis
Autoimmune Disease
Diabetes
High blood pressure
Heart disease
High cholesterol
Thyroid
Eye injury
Eye surgery
Cataracts
Glaucoma
Other Please Specify ___________________ FAMILY MEDICAL / OCULAR HISTORY ❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
Blindness
Cataracts
Diabetes
Glaucoma
High Blood Pressure
Heart Disease
Macular degeneration
Other Please Specify ___________________ Are you interested in laser eye surgery?
❑Yes ❑No
DO YOU EXPERIENCE: ❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
❑Y ❑N
Blurry distance vision
Blurry intermediate/computer vision
Blurry close vision
Double vision
Sudden vision loss
Flashes of light
Floating spots
Watery eyes
Burning eyes
Dry eyes
Red eyes
Frequent headaches
Uncomfortable contact lenses
Other: Please Specify _______________
FOR CONTACT LENS WEARERS: Is there ever a time that you wish you didn’t have to wear
your glasses? ❑Y ❑N
Do you currently wear contact lenses? ❑Y ❑N
If yes? When?___________________________________
Hours per day? ___________________
How often do you throw them out? __________________
At what point do your contact lenses
feel dry? _______________________________________ How often?
❑ 5-7 days per week
❑ 1-4 days per week
❑ < 1 day per week
Hours worn per day?
_________________
What kind?
❑ soft disposable
❑ soft non-disposable
❑ rigid gas-permeable
❑ hybrid lens
❑ scleral lens
EYE HEALTH
❑Y ❑N Amblyopia (Lazy eye)
❑Y ❑N Burning Eyes
❑Y ❑N Cataracts
❑Y ❑N Corneal Transplant
❑Y ❑N Double / Distorted Vision
❑Y ❑N Drooping Eyelid
❑Y ❑N Eye Surgery
❑Y ❑N Eye Turn
❑Y ❑N Floaters / Spots
❑Y ❑N Fluctuating Vision
❑Y ❑N Glaucoma
❑Y ❑N Glare / Light Sensitivity
❑Y ❑N Headaches
❑Y ❑N Itchy Feeling
❑Y ❑N Keratoconus
❑Y ❑N Loss of Vision
❑Y ❑N Mucus Discharge
❑Y ❑N Redness
❑Y ❑N Tearing
❑Y ❑N Other
Please Specify ____________________
MEDICATIONS
List all the medications taken by the patient and note that condition it is for
Medication
Condition
Medication
Condition
Please list all the names of the medications the patient is allergic to:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Emergency Contact _____________________________________________ Phone Number:______________________
Relationship to Patient: ______________________________________ Alternate Number:________________________