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Samoa
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Saudi Arabia
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Please locate your OHIP card
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Direct Billing Available
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Private Insurance
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Emergency Contact
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Contact Name
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12
Who is your family doctor?
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13
How did you find out about our office?
Prefer not to answer
internet
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Prefer not to answer
Prefer not to answer
internet
phone book
newspaper
friend/relative
physician referral
other
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Date of your last eye exam? (if its your first exam leave this section blank)
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15
What is the purpose of your eye examination?
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Are you interested in?
contact lenses
laser eye surgery
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17
Which Vehicle Licenses do you hold (please select all that apply):
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G, G1, G2
A
C
M, M1, M2
D
D
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Z endorsement
Pilot's License
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18
Is there a restriction on your license requiring you to wear corrective lenses when you drive?
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If you are unsure - take a look at your license.
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Yes
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19
What is your occupation / vocation?
Listing your occupation can help us determine any special visual needs that you have.
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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.
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21
Have you ever been diagnosed with an eye disease?
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Unsure
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Please describe any diagnoses you have received in the past.
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Have you ever had any eye surgery, eye infections or eye injuries?
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Please describe any eye surgeries, injuries or infections that you've had in the past.
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25
Have you ever had to complete any visual training or patching due to a lazy or cross eye?
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Yes
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26
How well are you seeing? Are you experiencing any of the following:
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blurred far vision
blurred near vision
double vision
trouble reading
poor night vision
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How do your eyes feel and look? Are you experiencing any of the following:
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soreness
itching
burning eyes
watering eyes
dry eyes
tired eyes
grittiness in eyes
redness
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Are you experiencing any of the following:
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floaters in vision
flashes of light
sensitivity to light
headaches
eye strain
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29
Do you wear vision correction or eye protection (eyeglasses, safety glasses, magnifiers, sunglasses)
No
Yes
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30
What type of vision correction do you have currently?
eyeglasses
contact lenses
safety glasses
sunglasses
magnifiers
Other
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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
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32
Do you wear contact lenses or have you worn them in the past?
No
Yes
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33
Are you still wearing contact lenses?
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Yes
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34
Why did you discontinue wearing contact lenses?
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35
Contact Lens Parameters
Brand
Diameter
Base Curve
Power Right Eye
Power Left Eye
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36
How many hours a day do you wear contact lenses when you choose to wear them?
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37
How many days/week, do you wear your contact lenses?
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38
Contact lens care system
Other
Clear Care
Opti-free Replenish
Solo-care
Renu
Bio-True
Complete
Opti-free Express
Other
Other
Clear Care
Opti-free Replenish
Solo-care
Renu
Bio-True
Complete
Opti-free Express
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39
Do you ever sleep in your contact lenses?
No
Yes
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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
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41
Do you have any other health conditions not listed previously?
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42
Please list all of the medications, vitamins, supplements, and eye drops that you take.
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43
Do you have any allergies or sensitivities (drug, environmental, food) ?
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No
Yes
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44
Please list all of your allergies or sensitivities (drug, environmental and food)
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45
Have you ever been a smoker?
No
Yes
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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
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47
Do you or does a family member have an eye conditions not listed above?
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48
Do you have any concerns that we need to be aware of?
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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
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Privacy Policy
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