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General Information

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Date

Date of Birth

Address

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Alberta Health Care Number

Telephone No. (Home)

Telephone No. (Work)

Telephone No. (Cell)

E-mail address*

Occupation

Do you currently have optical coverage?

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No

which company

Please list the main reason for this visit

Date of last eye exam

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Were you referred to our office?

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Where did you hear about us?

Glasses and Contact Lenses Information

Do 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 users

Do 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 lenses

Medication

Please list all medications you are currently taking and purpose (if any):

Drug

Purpose

Drug

Purpose

Drug

Purpose

Allergies (if any)

Ocular & Family History

Past 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

Other

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Other

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Dry Eye Quiz Results

Adult Information Form

General Information

Glasses and Contact Lenses Information

Current contact lens users

Medication

Ocular & Family History

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