20/10 Vision Associates Ancaster Patient History Form

20/10 Vision Associates Patient History Form

100 Legend Court Ancaster
Patient Name:*
Health Card number With Version Code*
Phone number*
Email:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Address*

Address

Street Address Line 2

City and Postal Code State / Province

Postal / Zip Code
Family Doctor:*
Preferred method of contact:*

EmailTextPhone
Personal Ocular History (Check all that apply)

GlaucomaCataractsRetinal DetachmentMacular DegenerationStrabismusAmblyopia /Lazy EyeBlindnessColour BlindnessOther
Family Ocular History (Check all that apply)

GlaucomaCataractsRetinal DetachmentMacular DegenerationStrabismusAmblyopia/Lazy EyeBlindnessColour BlindnessOther
Personal Medical History (Check all that apply):

High Blood PressureCholesterolDiabetes Type I/IICancerAsthmaSmokeEczemaCOPDAnxietyMultiple SclerosisRosaceaHeart DiseaseDevelopmental DisabilitiesThyroid DiseaseAttention Deficit DisorderSleep ApneaPsoriasisCrohn's DiseaseArthritisVascular DiseaseENTDepressionStrokeHerpes SimplexOther
Do you take any medications?*

NoYes
If yes, please list the medications below *
Do you have any allergies*

NoYes
If yes, please list the allergies below
Have you had any medical eye condition/surgery?*

NoYes
If yes, please explain previous eye condition/surgery below
Have you experienced any of the following? (Check all that apply)

Blurry visionGlare/reflections/haloesPoor night visionEye painLight sensitivityDouble visionItchy eyesTraumaHeadachesTearingDischargeRed eyesBurningFloaters/spots
What is the main reason for today’s visit?*
Our doctors highly recommend all patients receive our digital retinal imaging test (Optical Coherence Tomography or OCT) It assists in early detection of ocular disease as early detection can be a positive factor towards overall condition severity and allows us to better treat and manage your condition. There is an additional fee of $60 for patients 20yrs. old and up, also $35 for patients between 10yrs.old - 19 yrs. old for this evaluation (not covered by OHIP but reimbursable under most health/vision plans).
Please indicate whether you would like to have the digital retinal images taken and evaluated today:*

YesNo
Should be Empty:

20/10 Vision Associates Patient History Form