Patient History Form

Do you currently have an appointment scheduled?

YesNo, I would like to be contacted
Due to high demand our office is currently not accepting new patients at this time. We apologize for any inconvenience and appreciate your understanding.

If you have any questions, please feel free to contact our office.
Patient History Form

Welcome to Century Vision Care. We aim to address and fulfill all of your eye care needs. By completing this form, you will assist us in personalizing a comprehensive eye exam.
Patient Name*

PrefixFirst NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Age*
Parent/Guardian (If under 18 years)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Patient E-Mail
Preferred Method of Contact

TextEmailCellHomeWork
Current Occupation
Alberta Health Care #
Vision Insurance

Blue CrossCanada LifeSunlifeGreenshieldRCMPManulifeNIHBAlberta WorksNoneOther
File Uplaod

Browse Files
Please upload a picture of your Insurance card(s) if available Cancelof
Reason for Today's visit

RoutineDiabetic Health ExamOther
Approximate Date of Last Eye Exam?
Do you currently wear Glasses?

YESNO
Do you currently wear Sunglasses?

YESNO
Do you currently wear Contact Lenses?

YESDAILIESMONTHLYNOOther
Are you interested in contact lenses today?

YESNO
Have you ever had Cataract Surgery?

YESNO
When and which Doctor?
Have you had any other eye Surgery?

YESNO
Please Explain
Medical and Ocular History

(Please check all that apply)

OCULAR

	Self	Family
Cataracts
Glaucoma
Lazy Eye
Iritis/Uveitis
Retinal Detachment
Macular Degeneration
Keratoconus

MEDICAL

	Self	Family
Diabetes
Heart Disease
Thyroid
High Blood Pressure

Other
Are you currently using any eye drops? If yes, please list
Are you currently using any Medications? If yes, please list
Do you have any Allergies? If yes, please list
Who is your Family Doctor?
Who can we thank for referring you?
Ask about our 'Referral Rewards Program'
Additional Comments or Concerns
Should be Empty:

Patient History Form

Medical and Ocular History