Patient Information

Name

First Middle Last Suffix

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email Address*

How do you prefer that we contact you?*

OHIP number*

OHIP Version Code*

The two letters behind the OHIP number

OHIP Expiry Date*

Insurance Company Name

Are you covered by OHIP?

As 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

Glasses history

What 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 History

When 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 conditions

Please check all that apply

how much?

Eye Conditions

Please 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 List

Please list your existing medical conditions. If a specific condition is not listed below, please select other.

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

Signature

Date

Consent

I agree to the privacy policy.

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Adult form

Patient Information

Glasses history

Medical History

Medical conditions

Eye Conditions

Medication List

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