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?