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Located at the corner of Lansdowne Ave. and Coleman St.

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Home » Patient Health Questionnaire

Patient Health Questionnaire

Select Your Doctor*
Full Name (as appears on health Card)*
Date of Birth
MM slash DD slash YYYY
Sex
- M
- F
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact number (cell phone)
Contact number (home)
Contact number (work)
Email Address*
Family doctor
Health card number
How did you hear about our office?
- online
- walk-by
- friend/relative
- family doctor
- Another optometrist/ophthalmologist
- newspaper
Occupation
Do you wear contact lenses?
- Yes
- No
Are you happy with your current contact lenses? (i.e comfort and vision)
- Yes
- No
If no- why
Ocular history
Have you been diagnosed with and/or presently treated for any eye diseases?
- Glaucoma
- Macular degeneration
- Cataracts
- Retinal tear/detachment
- Other
Have you ever had any eye surgeries? (i.e. cataract surgery)
- Yes
- No
Please list (Approximate date and surgeon)
Do you have any known drug allergies?
Are you taking any medication/supplements or eye drops? - please list
Are you being treated for any of the following conditions?
- High blood pressure
- Diabetes
- Heart disease
- High cholesterol
- Thyroid disease
- Asthma
- COPD
- Arthritis
- Cancer
- Gastrointestinal disease
- other
- NONE
Is there a family history (immediate blood relative) of any of the following conditions?
- Macular degeneration
- Retinal Detachment
- Cataract
- Glaucoma
- Strabismus (eye turn)
- Blindness
- NONE

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Heritage Optometric Clinic

130 Lansdowne Avenue,. Suite 6
Carleton Place, ON K7C 2T7

Monday: 8:00 AM - 6:00 PM
Tuesday: 8:00 AM - 8:00 PM
Wednesday: 8:00 AM - 6:00 PM
Thursday: 8:00 AM - 8:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Heritage Optometric Clinic - Located at 130 Lansdowne Avenue,. Suite 6, Carleton Place, ON K7C 2T7. https://www.heritageoptometric.ca

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