Step 1 of 5 20% CONTACT INFORMATIONThank you for taking 4-5 minutes to ensure we have the most up to date information on your file in our office. Collecting and confirming this information in advance will help minimize your time in office and improve office safety measures.Name of your doctor :Dr W ClarkeDr T MerwiakDr M ScottDr J LauDr J ZaguryDr K MacDiarmidDr K NorthDate of your appointment :Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay*12345678910111213141516171819202122232425262728293031Year*202020212022Name* First Last Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell PhoneWork PhoneEmail Address My preferred contact method is :*EmailCell PhoneHome PhoneWork PhoneDate of BirthMonth*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay*12345678910111213141516171819202122232425262728293031Year*2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Health card number 2 Letter Version Code Family Doctor Name Family Doctor PhoneDo you have any particular concerns about your eyes or vision at this time?* Yes No Please describe your concerns : EYE / VISION HISTORYYour answers to these questions will guide us in our examination procedures to ensure that all your vision and eye health needs are met.Do you or have you experienced any of the following?* Blurry vision Loss of vision Double vision (seeing 2 of something) Halos around lights Excess glare Light sensitivity Dry/Stinging/Gritty eyes Watery eyes Mucous discharge from eyes Itchy eyes Red eyes Flashes of light in your vision? Floating spots in your vision? None of the Above Are the flashes of light in your vision central or to the side ?*CentralTo the sideHave the floating spots increased since you were last seen in our office?* Yes No Have you had any eye infections or injuries since you were last seen in our office* Yes No Please describe the eye infection or injury* Have you had any head injuries or concussions since you were last seen in our office?* Yes No Please describe the head injury or concussion* MEDICALMany medical conditions and medications have an effect on the eyes and possibly your vision. Your answers to these questions will guide us in your examination.Are you currently taking any medications?* Yes No Please list any medications : Do you have any allergies?* Yes No Please list any allergies: Are you currently using any eye drops? Yes No What brand of eye drops do you use? Please select any current conditions that apply to you or your family members:DIABETES Myself Parent Sibling Child Other No one HIGH BLOOD PRESSURE Myself Parent Sibling Child Other No one HEART DISEASE Myself Parent Sibling Child Other No one STROKE Myself Parent Sibling Child Other No one HIGH CHOLESTROL Myself Parent Sibling Child Other No one ASTHMA Myself Parent Sibling Child Other No one ARTHRITIS Myself Parent Sibling Child Other No one CANCER Myself Parent Sibling Child Other No one CATARACTS Myself Parent Sibling Child Other No one MACULAR DEGENERATION Myself Parent Sibling Child Other No one GLAUCOMA Myself Parent Sibling Child Other No one CROSSES / LAZY EYE Myself Parent Sibling Child Other No one BLINDNESS Myself Parent Sibling Child Other No one RETINAL DETACHMENT Myself Parent Sibling Child Other No one OTHER Myself Parent Sibling Child Other No one Other Please describe CORRECTIVE LENS INFORMATIONYour answers to these questions will guide us in recommending the best products to meet your eyewear needs. Do you wear any of the following?* Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses Safety Glasses Sport glasses/goggles I don’t wear any of these What do you use most of the time? Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses Safety Glasses Sport glasses/goggles I don’t wear any of these How old are your current glasses in years? Are your current glasses in need of an update? Yes No Are your prescription sunglasses transitions? Yes No Do you have a back up pair of glasses? Yes No Are your backup glasses your current prescription? Yes No Are you interested in new thinner lighter lenses? Yes No Are you interested in anti-fog lens options? Yes No Because we are now booking an appointment for everything in out office, including looking at glasses or getting new lenses in glasses. If you think you might need new lenses or glasses we recommend you request an appointment with one of our optical staff at the same time as your eye exam.I would like to book a time to review glasses when I am at the office for my eye exam? Yes No CONTACT LENSESWhat Brand of contact lenses do you wear?AcuVueAlconBausch+LombCooperVisionOtherOther contact lens brand What brand of solutions do you use to clean your lenses?BioTrueClearCareOptiFreeReNuOtherNoneOther contact lens solution On an average week how many days to you wear your contacts? In an average day how many hours do you wear your contacts? How often do you sleep in your lenses?NeverOccasionallyFrequentlyHow often do you replace or dispose your contact lenses?DailyEvery 2 weeksOnce a monthLonger than one monthAre you having any comfort or vision issues with your contact lenses? Yes No How many days old is the pair you are wearing now? How old is your contact lens case?0 - 3 months3 - 6 monthsover 6 months VISUAL NEEDSKnowing the way you use your eyes on a daily basis will help us make appropriate recommendations for visual comfort and safety.Employment StatusEmployed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerEmployment role and description How many hours a day do you use a computer/look at a screen? What type of device do you use the most?DesktopLaptopTabletSmartPhonePATIENT PRIVACY AND CONSENTWe are committed to protecting the privacy of our patients’ personal information and to utilizing all information in a responsible and professional manner. Our purposes for collecting, using and disclosing your personal information will be limited to those which are related to providing you with clinical care and optical products and services. This may include using such information to send you recalls and appointment reminders. Personal information will only be shared when clinically necessary for referrals and ongoing care. Merivale Vision Care and Wellington Vision Care are separate but integrated clinics. Our doctors work in both offices and will view your information at the location you are being seen.Consent I hereby consent to the collection, use and disclosure of my personal information as set out above. * Oops! We could not locate your form.