Patient Health Questionnaire

Select Your Doctor*

Full Name (as appears on health Card)*

Date of Birth

Sex

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?

Occupation

Do you wear contact lenses?

Are you happy with your current contact lenses? (i.e comfort and vision)

If no- why

Ocular history

Have you been diagnosed with and/or presently treated for any eye diseases?

Have you ever had any eye surgeries? (i.e. cataract surgery)

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?

Is there a family history (immediate blood relative) of any of the following conditions?