Adult form As a member of the Ontario Association of Optometrists, we are participating in a job action against the Ontario Government. We apologize for any inconvenience, as at this time we are NOT seeing patients covered by OHIP for their eye examination, including children/teens up to age 19, Seniors over age 65, diabetics and other conditions. Please call our clinic for more information.Patient InformationName First Middle Last Suffix Date of Birth* MM slash DD slash YYYY Address 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 Phone Number*Email Address* How do you prefer that we contact you?* OHIP number* OHIP Version Code* The two letters behind the OHIP numberOHIP Expiry Date* Insurance Company Name Are you covered by OHIP?Yes I have OHIP coverageNo I pay for my eye examThird ChoiceAs you may already know, the Ontario Association of Optometrists is participating in a job action against the Ontario Government. Bolton Optometry is participating in this job action. How does this affect me? At this time, we are not seeing patients covered by OHIP for their eye examination. OHIP covers eye examinations for: • children/teens up to age 19 • Seniors (over 65 years of age) • diabetics • some other conditions Insurance Company Client reference(#) Insurance Company Policy Number Please 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 own How 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? Yes No Do you Smoke? Yes No Do 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 above Please 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? Yes No Medication ListPlease list your existing medical conditions. If a specific condition is not 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 take Please list any drug allergies you have* I have read and agree to the Privacy Policy SignatureDate MM slash DD slash YYYY Consent I agree to the privacy policy.Untitled Section BreakUntitledUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird Choice
