Adult Vision and Eye Health History Form

Salutation
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First Name*
Please enter your first name.

Last Name*
Please enter your last name.

Date of Birth*
/ / Please enter your birthday.

Address 1*
Please enter your address.

City*
Please enter your city.

Postal Code*
Please enter your postal code.

Home Phone*
Please enter your home phone.

Cell Phone
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Email Address*
Please enter a valid email address.

Health Card #*
Please enter your health card number.

Insurance Policy and ID Number
Please enter your Insurance Policy and ID Number

Health Card Version Code
Please enter the health card version code.

Note: Version code is the two letters after the OHIP # and is not present on all cards.

Health Card Expiry Date
Please enter the health card expiry date.

Note: Not present on all cards.

Occupation
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Hobbies
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Referred by
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When was your last eye exam?
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By Dr.
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When was your last complete medical exam?
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Family Physician’s Name
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Phone
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Do you currently wear glasses?
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Do you currently wear contacts?
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Are you interested in trying contact lenses?
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Are you interested in laser vision correction (refractive surgery)?
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Reason for today's visit
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Any history of previous ocular training or injury or surgery or patching? Please describe
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Please indicate any problems you have with your vision
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Do you work at a computer?
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# hours per day
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Have you ever had any of the following:
Please describe
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Do you have any of the following problems with your eyes or eyelids?
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Please indicate problem
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Do you have any blood relatives who have had any ocular problems? If yes, please describe
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Please describe
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Do you have any longstanding medical problems?
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Please list all medications you are taking and indicate the condition or reason you are taking such medication.
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Please list anything you are allergic to, including medications, eye-drops, or ointments.
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Security question*
Security question
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Thank you. This information will greatly aid in the consideration and assessment of your ocular health, comfort and vision.