Patient questionnaire | Woodstock, Optometrist - Drs. Brant, Khanna & Thornton

1
Today's date* This field is required.
Date
Day
Month
Year
2
Full Name* This field is required.Please enter your full name
First Name
Last Name
3
Please Confirm Your Date of Birth* This field is required.
Date
Month
Day
Year
4
Please Confirm Your E-mail Address:* This field is required.Please provide your e-mail address
5
Please Confirm Contact Number* This field is required.
Area Code
Phone Number
6
Address* This field is required.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
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Afghanistan
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Please confirm your Ontario health card number and the last two letters
8
Who is your family doctor?
9
Date of Last Eye Exam
Date
Month
Day
Year
10
What is the purpose of your eye examination?* This field is required.What is the purpose of your visit?
11
Are you currently or have you recently experienced any of the following?* This field is required.
Fever
Cough
Shortness of Breath
Any known exposure to COVID-19 and/or traveled from a known hot spot in the past 14 days
None of the Above
12
How well are you seeing? Are you experiencing any of the following:Please check all that apply
blurred far vision
blurred near vision
double vision
trouble reading
poor night vision
Other
13
How do your eyes feel and look? Are you experiencing any of the following:Please check all that apply
soreness
itching
burning eyes
watering eyes
dry eyes
tired eyes
grittiness in eyes
redness
Other
14
Are you experiencing any of the following:Please check all that apply
floaters in vision
flashes of light
sensitivity to light
headaches
eye strain
Other
15
Do you wear contact lenses or have you worn them in the past?
No
Yes
16
Are you having any problems with your contact lenses?
No
Yes
17
Please list your health conditions
-
18
Please list all of the medications, vitamins, supplements, and eye drops that you take.
-
19
Do you have any allergies or sensitivities (drug, environmental, food) ?* This field is required.
No
Yes
20
Please list all of your allergies or sensitivities (drug, environmental and food)
-
21
Do you have any concerns that we need to be aware of?Describe any allergies or sensitivities that you may have.
-
22
Terms and Conditions* This field is required.
23

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