SPEED UP YOUR VISIT. PRINT AND COMPLETE THIS FORM. BRING THIS FORM, YOUR OHIP CARD, OLD PHOTOS AND HEAD SCANS (CT, MRI) TO US. WEAR GLASSES INSTEAD OF CONTACTS. AVOID MAKE-UP. SOME VISITS MAY REQUIRE 3 HOURS.
Last Name: First Name:
Age: BIRTHDAY: Month Day Year
Gender: Male / Female
OHIP #:
Address:
Home Phone #:
Referring doctor:
Your Job:
Work #:
MEDICAL PROBLEMS: (CIRCLE THE CONDITION IF YOU HAVE IT. CROSS OUT IF YOU DON’T HAVE IT, OR NEVER HEARD OF THE PROBLEM BEFORE.)
Cancer, Leukemia, Lymphoma, Melanoma (past or present)
Biopsy/Chemotherapy/Radiation
Diabetes (how many years)
Stroke / TIA (are you right or left handed)
High blood pressure
Hi cholesterol
Heart attack/Angina, CHF, Arrythmia
Asthma, Breathing trouble, Sleep apnea
Hepatitis / HIV / Syphilis / Tuberculosis
Sickle cell anemia, Blood disorder, Transfusion
Steroid use, Sarcoidosis
Thyroid trouble, Radioactive iodine, Smoking
Sinus surgery, Hearing problem
Weight Loss / Fever / Chills
Skin rash
Seizure / Multiple Sclerosis
Depression, Schizophrenia, Manic
Rheumatoid arthritis/Osteoarthritis
Lupus / vasculitis
Stomach ulcer / Crohns / GI
Kidney stone / Bloody urine / Kidney infections
Pacemaker/Metal/Claustrophobia
MEDICATIONS (Name all Pills, Injections, Puffers)
?Aspirin ?Plavix ?Coumadin ?Pradax ?Xarelto ?Vitamin E ?Gingko ?Ginseng
? Warfarin ? Dabigatran ? Rivaroxaban ?Apixaban
EYE DROPS (Glaucoma, Tears , Steroids)
ALLERGIES:
PAST HISTORY:
Operations, Malignant Hyperthermia, Trauma, Hospitalizations
EYE PROBLEMS
Surgery / Laser, Trauma, Patching, Cross Eyed, Premature birth
SOCIAL HISTORY Street Drugs, Alcohol, Tobacco, Military Service
FAMILY HISTORY
Malignant Hyperthermia (anaesthetic allergy)
Blindness (?maternal uncles), Glaucoma, Crossed Eyes, Unknown
WHAT BOTHERS YOU THE MOST ABOUT YOUR EYES?
HOW LONG HAS IT BEEN HAPPENING?
IS IT ON THE RIGHT / LEFT SIDE / BOTH SIDES?
DO YOU HAVE PROBLEMS WITH DISTANCE VISION (T.V. / DRIVING)?
DO YOU SEE DOUBLE? DOES THE DOUBLE VISION GO AWAY WHEN YOU CLOSE EITHER EYE?