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
*
Mr.
Mrs.
Ms.
Miss.
Mstr.
Dr.
Mx.
Prefix
First Name
Last Name
Preferred Name
Date of Birth
*
/
Month
/
Day
Year
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Age
*
Parent/Guardian (If under 18 years)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Patient E-Mail
Preferred Method of Contact
Text
Email
Cell
Home
Work
Current Occupation
Alberta Health Care #
Vision Insurance
Blue Cross
Canada Life
Sunlife
Greenshield
RCMP
Manulife
NIHB
Alberta Works
None
Other
File Uplaod
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Please upload a picture of your Insurance card(s) if available
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of
Reason for Today's visit
Routine
Diabetic Health Exam
Other
Approximate Date of Last Eye Exam?
Do you currently wear Glasses?
YES
NO
Do you currently wear Sunglasses?
YES
NO
Do you currently wear Contact Lenses?
YES
DAILIES
MONTHLY
NO
Other
Are you interested in contact lenses today?
YES
NO
Have you ever had Cataract Surgery?
YES
NO
When and which Doctor?
Have you had any other eye Surgery?
YES
NO
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
Do you currently have an appointment scheduled?
Yes
No, I would like to be contacted
Submit
Should be Empty: