Bloor West Optometry Adult Vision and Eye Health History Form Eye Health History Please fill out and submit the following form. SalutationMs.Mrs.Mr.Miss.Mstr.Dr.MxName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone(Required)Cell PhoneEmail Address(Required) Health Card #(Required)Insurance Policy and ID NumberHealth Card Version Code Note: Version code is the two letters after the OHIP # and is not present on all cards. Health Card Expiry Date Note: Not present on all cards.Occupation Hobbies Referred By When was your last eye exam? MM slash DD slash YYYY By Doctor When was your last complete medical exam? MM slash DD slash YYYY Family Physician’s Name PhoneDo you currently wear glasses? Yes No type of glasses full-time distance only reading only Do you currently wear contacts? Yes No type of contacts soft lenses gas permeable lenses Are you interested in trying contact lenses? Yes No Are you interested in laser vision correction (refractive surgery)? Yes No Reason for today's visitAny history of previous ocular training or injury or surgery or patching? Please describePlease indicate any problems you have with your vision None/Check up Blurred distance vision Flashes of light Spots before your eyes (floaters) Blurred near vision Loss of peripheral (side) vision Temporary loss of vision Blurred vision at the computer Partial loss or grayness of vision Double vision Blurred vision at arms length Poor night vision Difficulty identifying colours Rainbows around lights Other Problem headaches Please describe Do you work at a computer? Yes No # of hours per dayDo you have any of the following problems with your eyes or eyelids? Pain Frequent eye infections Eyes red or bloodshot Sore, dry or tired Frequent styes Eyelids red or swollen Gritty, burning or sandy Loss of eyelashes Eyes sensitive to light Itchy Eyelids stuck together in morning Waters a lot Excessive discharge Retinal problem Macular degeneration Diabetes Cataract Glaucoma Eye turn in/out (Lazy eye) Other Do you have any blood relatives who have had any ocular problems? If yes, please indicate: Retinal problem Macular degeneration Diabetes Cataract Glaucoma Eye turn in/out (lazy eye) Other Please describe Do you have any longstanding medical problems?Please list all medications you are taking and indicate the condition or reason you are taking such medication.Please list anything you are allergic to, including medications, eye-drops, or ointments.If the referral to another practitioner is necessary, I authorize the release of the required information. If the referral to another practitioner is necessary, I authorize the release of the required information. Bloor West Optometry
