Patient History Form Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Location*SelectBay College Optometric Centre - TorontoDr. A. Kara & Associates - MississaugaPatient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Number* Please provide a telephone number, with area code, so we can contact you.Daytime PhoneCell PhoneEmail Address Please provide us your email address.Additional InformationHow were you referred to our office?Select Referral Type >Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherReferral Status - Other Please let us know how you were referred to our office.Communication PreferenceSelect Communication Preference >EmailPostalTelephoneEye HistoryPlease check off any current conditions you suffer from I stopped wearing glasses I stopped wearing contact lenses Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision Have you ever experienced surgery / trauma / injury to the eye? Please specify. I stopped wearing glasses because: I stopped wearing contact lenses because: Please check off any conditions that you and/or a family membersuffers from. Diabetes High Blood Pressure Heart Disease Macular Degeneration Glaucoma Other Glasses HistoryDo you wear glasses?* Yes No What glasses do you own? Single Vision Bifocals Safety Glasses Backup Glasses Progressive Trifocals Sports Glasses Sunglasses Other Other glasses: Please tell us what other kinds of glasses you own.How many hours a day do you use a computer?Please enter a number from 0 to 24.How many inches away, approximately, do you sit from your computer monitor?Please enter a number from 0 to 120.Please check off any current conditions you suffer from I am having problems with my current glasses There are times when I would rather not be wearing glasses I have problems with glare I have problems with night vision I am allergic to nickel (e.g. frames of glasses) I don’t have spare set of glasses My spare glasses have an incorrect prescription My sunglasses are missing UV (ultra-violet) protection Contact Lens HistoryDo you wear contact lenses?* Yes No What brand of contact lenses do you wear? How old are your current lenses? How often do you replace or dispose your contact lenses? What brand of solution do you soak your lenses in? What is your typical wearing schedule? In hours per day:Please enter a number from 0 to 24.What is your typical wearing schedule? In days per week:Please enter a number from 0 to 7.Please check off all that apply to you I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I am interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription Medical HistoryWhen, approximately, was your last eye exam? Current medications*CommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy PhoneThis field is for validation purposes and should be left unchanged.
