Patient History Form

Please fill in as much information as you can provide. Fields marked with * are required.

Patient Information:

Frist Name *:
Last Name *:

Address *:
Address (Example Unit 1) :
City *:
Province *:
Post Code *:

Home Phone *:
Work Phone :
Cell Phone :

E-Mail :

Personal Information Below:

Date Of Birth *: Day Year
Gender :
Marital Status :
Job Discription and Employer :


Your Current Conditions (Please check off) : HeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision
I stopped wearing glasses because:
I stopped wearing contact lenses because:

What glasses do you own? : Single VisionBifocalsSafety GlassesBackup GlassesProgressiveTrifocalsSports GlassesSunglassesOther

Conditions You Suffer From : I am having problems with my current glassesThere are times when I would rather not be wearing glassesI have problems with glareI have problems with night visionI am allergic to nickel (e.g. frames of glasses)I don’t have spare set of glassesMy spare glasses have an incorrect prescriptionMy sunglasses are missing UV (ultra-violet) protection