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
Date of Birth* This field is required.
Date
Month
Day
Year
4
Address* This field is required.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
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
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.Please provide your preferred contact number
Please enter your phone
Please Select
Please Select
Cell
Home
Business
Type of phone
6
E-mailPlease provide your e-mail address
7
Please locate your OHIP cardFind your OHIP Health Number and Version Code
8
OHIP Health Number * This field is required.
OHIP Health Number
Two Letter Version Code
9
Direct Billing Available Convenient service available to pay for your services, glasses and contact lenses.
10
Private Insurance
None
None
Canada Life
Manulife
Sunlife
Medivae Blue Cross
Greenshield
RWAM
Other
11
Emergency ContactIn case of emergency
Contact Name
Please enter contact phone number
12
Who is your family doctor?
13
How did you find out about our office?
Prefer not to answer
Prefer not to answer
internet
phone book
newspaper
friend/relative
physician referral
other
14
Date of your last eye exam? (if its your first exam leave this section blank)
Date
Year
Month
Day
15
What is the purpose of your eye examination?* This field is required.What is the purpose of your visit?
-
16
Are you interested in?
contact lenses
laser eye surgery
Other
17
Which Vehicle Licenses do you hold (please select all that apply):Please check all that apply
G, G1, G2
A
C
M, M1, M2
D
D
E
F
Z endorsement
Pilot's License
Other
18
Is there a restriction on your license requiring you to wear corrective lenses when you drive?* This field is required.If you are unsure - take a look at your license.
No
Yes
19
What is your occupation / vocation?Listing your occupation can help us determine any special visual needs that you have.
20
What are your hobbies ? What do you like to do in your spare time?Listing your hobbies / activities can help us determine your visual needs.
21
Have you ever been diagnosed with an eye disease?* This field is required.
No
Yes
Unsure
22
Please describe any diagnoses you have received in the past.
-
23
Have you ever had any eye surgery, eye infections or eye injuries?* This field is required.
No
Yes
24
Please describe any eye surgeries, injuries or infections that you've had in the past.
-
25
Have you ever had to complete any visual training or patching due to a lazy or cross eye?
No
Yes
26
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
27
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
28
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
29
Do you wear vision correction or eye protection (eyeglasses, safety glasses, magnifiers, sunglasses)
No
Yes
30
What type of vision correction do you have currently?
eyeglasses
contact lenses
safety glasses
sunglasses
magnifiers
Other
31
How many hours do you spend using a computer / tablet / smartphone?
never use
0-2 hours / day
3-4 hours / day
more than 5 hours / day
32
Do you wear contact lenses or have you worn them in the past?
No
Yes
33
Are you still wearing contact lenses?
No
Yes
34
Why did you discontinue wearing contact lenses?
35
Contact Lens Parameters
Brand
Diameter
Base Curve
Power Right Eye
Power Left Eye
36
How many hours a day do you wear contact lenses when you choose to wear them?
37
How many days/week, do you wear your contact lenses?
38
Contact lens care system
Other
Other
Clear Care
Opti-free Replenish
Solo-care
Renu
Bio-True
Complete
Opti-free Express
39
Do you ever sleep in your contact lenses?
No
Yes
40
Please check the health conditions that apply to you or a relative by blood
Yourself
Child
Sibling
Mother / Mother's side
Father / Father's side
Asthma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Cancer
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Cardiac Disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Diabetes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Hypertension
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Thyroid
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Arthritis
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Stroke
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
MS
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Sleep Apnea
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Hypotension
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Migraine
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Asthma
Cancer
Cardiac Disease
Diabetes
Hypertension
Thyroid
Arthritis
Stroke
MS
Sleep Apnea
Hypotension
Migraine
Yourself
Row 0, Column 0
Child
Row 0, Column 1
Sibling
Row 0, Column 2
Mother / Mother's side
Row 0, Column 3
Father / Father's side
Row 0, Column 4
Yourself
Row 1, Column 0
Child
Row 1, Column 1
Sibling
Row 1, Column 2
Mother / Mother's side
Row 1, Column 3
Father / Father's side
Row 1, Column 4
Yourself
Row 2, Column 0
Child
Row 2, Column 1
Sibling
Row 2, Column 2
Mother / Mother's side
Row 2, Column 3
Father / Father's side
Row 2, Column 4
Yourself
Row 3, Column 0
Child
Row 3, Column 1
Sibling
Row 3, Column 2
Mother / Mother's side
Row 3, Column 3
Father / Father's side
Row 3, Column 4
Yourself
Row 4, Column 0
Child
Row 4, Column 1
Sibling
Row 4, Column 2
Mother / Mother's side
Row 4, Column 3
Father / Father's side
Row 4, Column 4
Yourself
Row 5, Column 0
Child
Row 5, Column 1
Sibling
Row 5, Column 2
Mother / Mother's side
Row 5, Column 3
Father / Father's side
Row 5, Column 4
Yourself
Row 6, Column 0
Child
Row 6, Column 1
Sibling
Row 6, Column 2
Mother / Mother's side
Row 6, Column 3
Father / Father's side
Row 6, Column 4
Yourself
Row 7, Column 0
Child
Row 7, Column 1
Sibling
Row 7, Column 2
Mother / Mother's side
Row 7, Column 3
Father / Father's side
Row 7, Column 4
Yourself
Row 8, Column 0
Child
Row 8, Column 1
Sibling
Row 8, Column 2
Mother / Mother's side
Row 8, Column 3
Father / Father's side
Row 8, Column 4
Yourself
Row 9, Column 0
Child
Row 9, Column 1
Sibling
Row 9, Column 2
Mother / Mother's side
Row 9, Column 3
Father / Father's side
Row 9, Column 4
Yourself
Row 10, Column 0
Child
Row 10, Column 1
Sibling
Row 10, Column 2
Mother / Mother's side
Row 10, Column 3
Father / Father's side
Row 10, Column 4
Yourself
Row 11, Column 0
Child
Row 11, Column 1
Sibling
Row 11, Column 2
Mother / Mother's side
Row 11, Column 3
Father / Father's side
Row 11, Column 4
1 of 12
41
Do you have any other health conditions not listed previously?
-
42
Please list all of the medications, vitamins, supplements, and eye drops that you take.
-
43
Do you have any allergies or sensitivities (drug, environmental, food) ?* This field is required.
No
Yes
44
Please list all of your allergies or sensitivities (drug, environmental and food)
-
45
Have you ever been a smoker?
No
Yes
46
Please check the eye conditions that apply to you or a blood relative
Yourself
Child
Sibling
Mother/Mother's side
Father/Father's side
Glaucoma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Cataract
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Macular degeneration
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Lazy or crossed eyes
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Retinal detachment
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Blindness
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Glaucoma
Cataract
Macular degeneration
Lazy or crossed eyes
Retinal detachment
Blindness
Yourself
Row 0, Column 0
Child
Row 0, Column 1
Sibling
Row 0, Column 2
Mother/Mother's side
Row 0, Column 3
Father/Father's side
Row 0, Column 4
Yourself
Row 1, Column 0
Child
Row 1, Column 1
Sibling
Row 1, Column 2
Mother/Mother's side
Row 1, Column 3
Father/Father's side
Row 1, Column 4
Yourself
Row 2, Column 0
Child
Row 2, Column 1
Sibling
Row 2, Column 2
Mother/Mother's side
Row 2, Column 3
Father/Father's side
Row 2, Column 4
Yourself
Row 3, Column 0
Child
Row 3, Column 1
Sibling
Row 3, Column 2
Mother/Mother's side
Row 3, Column 3
Father/Father's side
Row 3, Column 4
Yourself
Row 4, Column 0
Child
Row 4, Column 1
Sibling
Row 4, Column 2
Mother/Mother's side
Row 4, Column 3
Father/Father's side
Row 4, Column 4
Yourself
Row 5, Column 0
Child
Row 5, Column 1
Sibling
Row 5, Column 2
Mother/Mother's side
Row 5, Column 3
Father/Father's side
Row 5, Column 4
1 of 6
47
Do you or does a family member have an eye conditions not listed above?
-
48
Do you have any concerns that we need to be aware of?
-
49
Are you currently experiencing any of the following?
Fever
Cough
Shortness of Breath
Any known exposure to COVID-19 and/or travelled from a known hotspot in the past 14 days
None of the Above
50
Privacy Policy* This field is required.
51
Securely submit your questionnaire by pressing the submit button below.
Should be Empty: