New Patient Intake Form If you're new to our office, please fill out the form below so that we can get to know your ocular and medical history a bit better.PERSONAL DEMOGRAPHICSName* First Last Date of Birth* MM slash DD slash YYYY Preferred Phone*Type* Home Cell Work Secondary PhoneType Home Cell Work Email Preferred Method of Contact* Text Email Call Address* Street Address Address Line 2 City Province 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 HEALTH CARD (OHIP) INFORMATIONWe verify the eligibility of any OHIP eligible patients ahead of their appointments, if applicable.10 Digit Number* 2 Letter Version Code* Expiry Date* Year Month Day OCULAR HISTORYHave you had any eye surgeries?* Yes No If yes, please provide details: Do you wear glasses?* Yes No If yes, please choose all of the types: Distance Readers Bifocals Trifocals Progressives Sunglasses Do you wear contact lenses?* Yes No If yes, please elaborate: Full time Part time Interested in wearing If yes, please let us know what brand of contacts you wear: Are you currently experiencing any of the following problems with your eyes?*YesNoBurning/itchingDrynessRednessSandy/gritty feelingTearing/wateringBlurred visionDistorted visionDouble visionPeripheral vision lossTired/strained eyesEye pain/sorenessFlashes/floatersGlare/light sensitivityMucous dischargeStyes/chalazionMEDICAL HISTORYDo you have any allergies?* No Yes, medication(s) Yes, environmental Yes, other If yes, please provide details: Do you take any prescription or non-prescription medicines?* Yes No If yes, please list them or upload a copy of your med list below: Please upload a copy of your med list, if applicableMax. file size: 31 MB.Please indicate if you or any of your blood-relatives have the following:*SelfFamilyUnsureN/AVision ImpairmentCataractColour Vision DeficiencyGlaucomaKeratoconusStrabismusDiabetic RetinopathyMacular DegenerationRetinal DetachmentDry EyesHigh Blood PressureCancerDiabetesHeart DiseasePlease check any health conditions that you may have:* Neuologic (migraines, headaches, brain injury) Respiratory (asthma, COPD, sleep apnea) Psychiatric (depression, anxiety, ADHD, memory loss) Immunologic (rheumatoid arthritis, HIV, lupus) Endocrine (diabetes, hypo or hyperthyroid) Genitourinary (kidney disease, pregnancy, prostate disorder) Cancer Skin disorders (eczema, rosacea, psoriasis, cold sores, shingles) Muscle/joints (Marfan's syndrome, arthritis) Blood (anemia, blood clotting disorders, sickle cell, hepatitis) General constitution (fibromyalgia, developmental disabilities) Ear/nose/throat (hearing loss, sleep apnea, sinus infections) Cardiovascular (high blood pressure, cholesterol, heart disease, stroke) Gastrointestinal (IBS, Crohn's disease, colitis) Other None of the above If you checked any of the above health conditions, please specify:Section BreakPhoneThis field is for validation purposes and should be left unchanged.
