New Patient Registration Form

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?