Patient Health Questionnaire
Please fill out the following information prior to your appointment with Dr. Belliveau. Ensure all information is correct to further streamline your appointment and corresponding information/charting. All data is encrypted as to follow medical privacy protocols.
Patient Information
Full Name of Patient
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
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Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
If questionnaire was not completed by the patient, please provide the name of person filling out the form:
First Name
Last Name
Relation to patient:
Health Card Number (ex. MSI): (if you do not have a health card, type N/A)
*
Health Card Expiry:
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Month
-
Day
Year
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Doctor: (type N/A if you do not have a family doctor)
*
Optometrist and/or eye care centre: (type N/A if you do not have an optometrist)
*
Health Insurance Company: (type N/A if you do not have health insurance)
*
Complete all information on this page to continue.
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Medical History, Medications and Allergies
Have you/do you currently have any of the following: (check all that apply)
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Heart problems
Chest pain
Trouble breathing when lying flat
High blood pressure
Indigestion/heartburn
Blood clotting disorder
Diabetes
Thyroid problems
Kidney problems
Liver problems
Rheumatoid arthritis
Seizures
Cancer
Migraines
Communicable Disease
Blood-born Disease
Mobility Difficulty
Other
Specify your communicable disease(s):
*
Do you have MRSA and/or have been in contact with someone with MRSA?
*
Yes
No
Specify your blood-born disease(s):
*
Specify your heart problems:
*
Do you take insulin?
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Yes
No
Last blood sugar and/or A1C value and when taken (date, time..):
*
Specify your thyroid problems:
*
Specify your kidney problems:
*
Specify your liver problems:
*
Specify your cancer:
*
Have you had a fall before?
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Yes
No
Did this fall result in an injury?
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Yes
No
List all known allergies: (type N/A if you have no known allergies)
*
List any artificial tears and/or medicated eye drops that you currently use and their frequency: (type N/A if you do not use any eye drops)
*
List all medications, including over the counter drugs, pain pills, puffers, and vitamin supplements: (type N/A if you do not take any medications)
*
Have you ever taken and/or currently take: (multiple choice)
*
Blood thinners
Prostate medications (ex. Flomax; tamsulosin)
None of the above
List all previous surgeries and/or medical procedures: (type N/A if you have no medical history)
*
List previous eye surgeries and/or eye injuries that you have had, including approximate dates and applicable eye(s): (type N/A if you have no past ocular history)
*
Do you or a family member have a serious bleeding disorder?
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Yes
No
Do you or a family member have a negative response to anesthetics?
*
Yes
No
Is this negative response related to a condition called "Malignant Hyperthermia"?
*
Yes
No
Do you smoke?
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Yes
No
How many cigarettes do you smoke per day?
*
Do you drink alcohol?
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Yes
No
How many servings of alcohol do you drink per week?
*
Is there any chance that you could be pregnant?
*
Yes
No
Additional comments regarding medical history/conditions:
Complete all information on this page to continue.
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Miscellaneous History
Identify any known family history of eye conditions: (multiple choice)
*
Retinitis pigmentosa
Corneal dystrophy
Glaucoma
AMD (macular degeneration)
Aniridia
Retinoblastoma
None known or N/A
Other
To better guide a treatment plan and procure a suitable diagnosis, please list any current occupations or pertinent hobbies you may have: (type N/A if you are not comfortable answering)
*
Indicate which of the following you currently wear/use: (multiple choice)
*
Prescription glasses
Contact lenses
Reading glasses
None of the above
How old is your current prescription/glasses?
*
What type of contact lenses do you wear?
*
Soft (ex. dailies, disposable)
Hard (ex. RGPs, scleral)
Both
What "plus" readers do you use? (ex. +1.50, +2.75...)
*
Please indicate:
Weight:
pounds
*
lbs
Height:
feet
*
inches
*
Complete all information on this page to continue.
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Please note that if you wear any vision correction to please bring any/all current glasses and/or contact lenses to your eye appointment.
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Submit
Do NOT wear any SOFT contact lenses at least 3 days prior to your appointment.
Do NOT wear any HARD contact lenses at least 1 month prior to your appointment.
If this cannot be accommodated in time for your appointment, please contact us (902-444-4872) to reschedule to a more suitable time.
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