Medical History and Needs Form 1. Patient informationPlease fill out the following personal information Name* First Last Preferred NameDate of Birth MM slash DD slash YYYY Email Address Address Street Address Address Line 2 City Province Home Phone*Cell PhonePreferred Method of Contact: Tell us the best way to reach you Email Phone Text Family Doctor Yes No Do you have a family doctor?Family Doctor Phone NumberEmergency Contact Name First Last Emergency Contact Phone NumberEmergency Contact Email Insurance InformationDo you have medical insurance? Yes No Plan NamePolicy #Group #Do you have dependent coverage? Yes No Health Card InformationHealth card numberExpiry Date2. Personal medical historyPlease list any medical conditionsHave you been diagnosed with an eye disease?Please list any previous eye surgeriesPlease list all medications you are currently takingPlease list any allergiesPlease list any eye diseases that run in your family (Glaucoma, Macular Degeneration, etc)3. COVID-19 health historyDo you have fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing? Yes No Have you had close contact with anyone with acute respiratory illness or who has traveled outside of Canada in the past 14 days? Yes No Do you have a confirmed case of COVID-19 or have had close contact with a confirmed case of COVID-19? Yes No Have you travelled recently? Yes No If you answered yes to any of these questions, please explain below4. Purpose of your visite.g. regular eye exam, blurred vision, red eye etc. Please elaborate on any concerns in the box below:5. Corrective lens informationa) Do you wear the follow?Please check all that apply Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses don’t wear any of these b) What do you use most of the time?Please check all that apply Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses don’t wear any of these 6. Visual NeedsYour answers to these questions will guide us in recommending the best products to meet your eyewear needs.a) Employment InformationYour eyes are also working. Please tell us what you do for work. b) Job Description Please describe your job duties to usc) Which do you do regularly? Check all that apply Night Driving Work Outdoors Commute 20+ min. By Car Work w/Small Objects Work Under Fluorescent Light Read for Long Periods Work on a Computer Travel on Airplanes Watch TV for 3+ hrs/Day Work at a Desk Frequently Alternate Between Indoors & Outdoors d) Hobbies/RecreationTo help us better understand how you use your eyes, please list any recreational activities or hobbies that you enjoy. e) What do you like about your current glasses?f) Is there anything you do not like about your current glasses?g) What is important when choosing your new glasses? Please check all that apply. Image Frame Material Fit Durability Weight Brand Fashion Trends Lens Type Lens Thickness Frame Colour Lens Colour Price PLEASE BRING YOUR CURRENT GLASSES & SUNGLASSES TO YOUR EXAMHow did you hear about us? Family/Friend Google Website Appointment Walk By Family Doctor Other whoOther Thank you The Underhill Optometry team Δ
