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 / Other

OHIP #:                                                                          

Address:                                                                         

 

Home Phone #:                                                               

Referring doctor:                                                            

Occupation:                                                                    

Work #:                                                                         

email:  ____________________________________

 

MEDICAL PROBLEMS:  (CIRCLE THE CONDITION IF YOU HAVE IT.  CROSS OUT IF YOU DON’T HAVE IT, OR NOT 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        

Smoking  (cigarettes, vaping, marijuana, pipe)     

Asthma, Breathing trouble, Sleep apnea                  

Hepatitis / HIV / Syphilis / Tuberculosis    

Sickle cell anemia, Blood disorder, Transfusion                  

Steroid use,   Sarcoidosis, IgG4 disease                           

Thyroid trouble, Radioactive iodine

Sinus surgery, Hearing problem

Weight Loss / Fever / Chills / Tender scalp / Sore shoulders / Cheek muscle pain with chewing

Seizure / Multiple Sclerosis / Myasthenia gravis     

Depression, Schizophrenia, Manic

Neck injury / Neck fusion

Skin rash

Rheumatoid arthritis/Osteoarthritis

Lupus / vasculitis

Stomach ulcer / Acid reflux / Crohns / Ulcerative colitis / GI

Kidney stone / Bloody urine / Kidney infections

Pacemaker/ Metal in body / Claustrophobia

 

MEDICATIONS  (Name all Pills, Injections, Puffers)

           

 

 

                              

 

?Aspirin ?Plavix  ?Coumadin/Warfarin  ?Pradaxa (dabigatran) ?Xarelto (rivaroxaban)

 ?Eliquis (apixaban)  ?Lixiana (edoxaban)      ?Vitamin E  ?Gingko ?Ginseng

 

EYE DROPS / OINTMENTS (Glaucoma, Tears          , Steroids)

 

 

ALLERGIES:

 

 

PAST HISTORY:                                                     

Operations, Malignant Hyperthermia, Trauma, Hospitalizations    

   

 

 

                                            

EYE PROBLEMS

Trauma, Patching, Cross Eyed, Premature birth

Surgery / Laser:  Cataract surgery,  Glaucoma Surgery,  Retina Surgery

 

 

SOCIAL HISTORY   Street Drugs, Alcohol, Tobacco, Military Service

 

                                     

 

FAMILY HISTORY  

Malignant Hyperthermia (allergic to anesthetic gas)

Blindness (?maternal uncles), Glaucoma, Crossed Eyes, Unknown

 

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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?