Adult Information Form Location*-- Select One --AirdrieBridgelandSouth Trail CrossingMacleod TrailPanorama HillsGeneral InformationName First Middle Last Date MM slash DD slash YYYY 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 Alberta Health Care NumberTelephone No. (Home)Telephone No. (Work)Telephone No. (Cell)E-mail address* OccupationDo you currently have optical coverage? Yes No which companyPlease list the main reason for this visitDate of last eye exam MM slash DD slash YYYY By DrWere you referred to our office? Yes No Where did you hear about us?Glasses and Contact Lenses InformationDo you currently use (please check all that apply)? Glasses full time Reading glasses Contact lenses (see below) Glasses part time Bifocals/progressive bifocal None Current contact lens usersDo you currently use contact lenses? Yes No What type of lenses do you use? RGP (hard) soft disposables What brand of contact lenses?How many years have you worn contact lenses?How many hours per day do you wear contact lenses?Age of current lensesMedicationPlease list all medications you are currently taking and purpose (if any):DrugPurposeDrugPurposeDrugPurposeAllergies (if any)Ocular & Family HistoryPast eye-related issues: (eg., injuries, infections, surgeries, etc.):Is there any family history of Glaucoma self mother father grand mother grand father Turned/lazy eye self mother father grand mother grand father Corneal dystrophy self mother father grand mother grand father Diabetes self mother father grand mother grand father Cataracts self mother father grand mother grand father Macular degeneration self mother father grand mother grand father Migraine headaches self mother father grand mother grand father Multiple sclerosis self mother father grand mother grand father Blindness self mother father grand mother grand father Retinal detachment self mother father grand mother grand father High blood pressure self mother father grand mother grand father Thyroid self mother father grand mother grand father Colour blindness self mother father grand mother grand father Flashes/floaters self mother father grand mother grand father Heart disease self mother father grand mother grand father OtherWould You Like Additional Information with the Following Anti-reflective lenses Scratch-resistant lenses Thinner/lighter lenses Sunglasses Transition lenses Computer glasses Sports glasses Eye vitamins Eye drops/dry eye Bifocal contact lenses Disposable contact lenses Sports vision therapy (please complete additional form) OtherThis office is in compliancy with Alberta Privacy Legislation and we will not collect, use, or disclose any personal information without prior consent. All information collected on this form and during the course of the examination are protected. EmailThis field is for validation purposes and should be left unchanged. Δ
