Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Is this for a patient under 18 years of age?*

Yes
No

Parent or Guardian Name*

Prefix First Last Suffix

Address*

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

Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address

Please provide us your email address.

Enter OHIP number and Version code

Health Card Expiry Date

Insurance Information

Provider Name:

Name On Card:

Policy number:

Member Id:

Personal Information

Date of Birth*

Preferred Language*

Visual needs

Your answers to these question will guide us in recommending the best products to meet your eyewear needs.

Our eyes are always working. Please tell us what you do for work.

Employment Information

Please describe your job duties to us.

Job Description

Check all that apply.

Which do you do regularly?

Night driving
Work outdoors
Commute 20+ min
Work w/small objects
Work on a computer
Travel on airplanes
Watch TV for 3+ hrs/day
Work at a Desk
Frequently Alternate Between Indoors & Outdoors

To help us understand how to use your eyes, please list any recreational activities or hobbies that you enjoy.

Hobbies/Recreation

How were you referred to our office?

Referral Status - Other

Please let us know how you were referred to our office.

Communication Preference

Please describe your condition or purpose of your visit.

Purpose of your visit

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses because:

I stopped wearing contact lenses because:

Glasses History

Do you wear glasses?*

Yes
No

What glasses do you own?

Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other

Other glasses:

Please tell us what other kinds of glasses you own.

How many hours a day do you use a computer?

Please enter a number from 0 to 24.

How many inches away, approximately, do you sit from your computer monitor?

Please enter a number from 0 to 120.

Please check off any current conditions you suffer from

I am having problems with my current glasses
There are times 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 spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

Contact Lens History

Do you wear contact lenses?*

Yes
No

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

Please check off all that apply to you

I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription

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?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

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 hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

COVID-19

Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?*

Yes
No

Have you traveled recently?*

Yes
No

Do you have a confirmed case of COVID-19 or have had close contact with a confirmed case of COVID-19?*

Yes
No

Have you had close contact with anyone with acute respiratory illness or traveled outside of Canada in the past 14 days?*

Yes
No

If you answered yes to any of these questions, please explain below.

Please bring you current GLASSES & SUNGLASSES to your exam.

Comments

If you have any comments you would like to add, please enter them here.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Signature*

Date*

Untitled

Email

This field is for validation purposes and should be left unchanged.

Patient History Form

Patient Information

Insurance Information

Personal Information

Visual needs

Eye History

Glasses History

Contact Lens History

Medical History

COVID-19

Please bring you current GLASSES & SUNGLASSES to your exam.

Comments

Privacy Policy

Shelburne Primary EyeCare