Adult form Patient InformationName First Middle Last Suffix Date of Birth* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number*Email Address* How do you prefer that we contact you?*OHIP number with Version Code*Insurance Company NameInsurance Company Client reference(#)Insurance Company Policy NumberPlease check off all that apply Blurred vision at near Blurred vision at distance glare/ light sensitivity Headaches Haloes Fluctuating Vision tired eyes burning dryness Watery eyes Eye pain and or Soreness Sandy or Gritty feeling itchy eyes infection of eye or lid Mucous discharge Redness Drooping eyelid(s) Amblyopia Strabismus (crossed eye) Double Vision Floaters or Spots Loss of Vision Loss of side Vision Glasses historyWhat Glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Sports Glasses Sunglasses other Tell us what other kinds of glasses you ownHow many hours a day do you use a computer?How far away, approximately, do you sit from your computer monitor? (cm or inches)Please check all that apply I am having problems with my current glasses there are time when I would rather not be wearing glasses I have problems with glare I have problems with night vision I am allergic to nickel (e.g. frames of glasses) I don't have a spare set of glasses my spare glasses have an incorrect prescription my sunglasses are missing UV Medical HistoryWhen approximately was your last eye exam?Where did you get your last eye exam?When, approximately was your last physical exam?Who is your primary care physician?Do you Drink alcohol?YesNoDo you Smoke?YesNoDo you use Cannabis products?Medical conditionsPlease check all that apply Hypertension Diabetes Heart issues Cholesterol issues Vasculitis, vascular surgery Cancer Thyroid dysfunction Depression, anxiety or mental problems Brain injury, stroke Smoking how much?Eye ConditionsPlease check all that apply Glaucoma Cataract Strabismus (wandering eye) Amblyopia (lazy eye) Retinal detachment Uveitis Other not listed abovePlease list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High Blood Pressure, Cancer, Glaucoma, Macular Degeneration etc.?Please list all the hospital surgeries you have ever had.Do you take medications?YesNoMedication ListPlease existing medical conditions you might have take. If not for a specific condition listed below, please select other. High Blood Pressure Diabetes Cholesterol Thyroid Arthritis Heart problems Breathing problems gastro-intestinal problems Glaucoma Other not listed What medication(s) do you take for high blood pressure?What medication(s) do you take for diabetes?What medication(s) do you take to manage cholesterol?What medication(s) do you take to manage your thyroid condition?What medication(s) do you take to manage your arthritis?What medication(s) do you take to manage your heart condition?What medication(s) do you take to manage your breathing problems?What medication(s) do you take to manage your GI condition(s)?What medication(s) do you take to manage your glaucoma?Please list the other medications you currently takePlease list any drug allergies you have* I have read and agree to the Privacy Policy SignatureDate Date Format: MM slash DD slash YYYY Consent I agree to the privacy policy.
