Adult Vision and Eye Health History Form

Salutation
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Date of Birth*
/ / Please enter your birthday.

First Name*
Please enter your first name.

Initial
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Last Name*
Please enter your last name.

Address 1*
Please enter your address.

Address 2
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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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Work Phone
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Email Address*
Please enter a valid email address.

Health Card #*
Please enter your health card 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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Do you have third-party insurance you would like us to bill?
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Note: If your provider is not listed you will need to submit a claim manually, we cannot bill direct

Division #
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Certificate #
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Firm #
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Certificate #
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Policy #
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Member ID #
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Group #
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Certificate #
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Division #
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Certificate #
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Policy #
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Member ID #
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Group #
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Certificate #
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Policy #
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ID #
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Policy #
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Certificate #
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Plan Contract #
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Member Certificate #
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Division #
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Certificate #
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Contract #
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Member ID #
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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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By Dr.
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Do you want a report of your vision exam to be sent to your family physician?
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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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Do you have a driver’s license?
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Is it restricted to the wearing of glasses?
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Reason for today's visit
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Please indicate any problems you have with your vision
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Please describe the other problem(s)
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Please describe your problem headaches
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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:
Eye vision training
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Eye patching
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Eye turn IN/OUT
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Eye injury
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Eye surgery
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Please describe
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Do you have any of the following problems with your eyes or eyelids?
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Do you have any blood relatives who have had eye health problems?
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Please indicate problem
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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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Do you have any of the following medical conditions?
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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.