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Financing
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Hours & Location
Online Store
About us
Contact us
Our Eye Doctors
Why Choose us
Community Outreach
Office Gallery
Eye Care Services
Myopia Management
TeleHealth For Optometry and Better Eye Care
Computer Vision Syndrome
Pediatric Eye Exams
Eye Disease Management
Presbyopia Diagnosis & Treatment
Eye Emergencies (Pink/Red Eyes)
Dry Eye
Eyewear & Contact Lenses
Eyewear
Lenses
Sunwear
Contact Lenses
Bifocal and Multifocal Contact Lenses
Gas Permeable (GP) Contact Lenses
Contact Lenses for the “Hard-to-Fit” Patient
Designer Frames
Financing
Insurance
Beautifi | Financing Made Simple
Hours & Location
Online Store
Patient History Form
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Mr.
Mrs.
Ms.
Mx.
Miss
Dr.
Prof.
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Middle Name
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Apartment, suite, etc
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Afghanistan
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Algeria
American Samoa
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Angola
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Antarctica
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Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Croatia
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Guinea-Bissau
Guyana
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Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
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Kenya
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Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
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Mali
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Nigeria
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Panama
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Somalia
South Africa
South Georgia and South Sandwich
Spain
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Stateless Persons
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Sudan, South
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Tajikistan
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Thailand
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Ukraine
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Uruguay
Uzbekistan
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Vatican City
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Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
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Phone
Daytime Phone
Cell Phone
Email Address
Personal Information
Gender
*
Male
Female
Date of Birth
*
BC Personal Health Card Number
Preferred Language
*
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English
Spanish
French
Japanese
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Occupation
How were you referred to our office?
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Family Doctor
Ophthalmologist
Insurance Company
Newspaper
Television
Radio
Received Mailing
Internet
Other Optometrist
Other
Communication Preference
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Email
Postal
Telephone
Eye History
Please check off any current conditions you suffer from
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
Glasses History
Do you wear glasses?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
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?
Select
No
Yes, 1 per week
Yes, 1 per day
Yes, 2 or 3 per day
Yes, 4 or more per day
Do you smoke?
Select
No
Yes, 1/2 a pack per day
Yes, 1 pack per day
Yes, more than 1 pack per day
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
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance
Policy Holder First Name
Policy Holder Last Name
Group Number
Identification Number
Insured's Date of Birth
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
Yes
No
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