Patient Intake Form

Clearer vision for a better life.

REQUEST AN APPOINTMENT

ORDER YOUR CONTACTS

Please fill in this form before your first visit to our office as a patient.

Please use the form below before you come to your initial appointment. All the fields followed by an asterisk (*) are required.

Dr. Lam, Dr. Blanchette and Dr. Macleod are accepting new patients.

All fields marked with an asterisk (*) are required.

Patient Intake Form

Name *

First

Last *

Last

Email *

Age *

Date of Birth *

Phone (home) *

Phone (cell)

Street Address *

City *

Province *

Postal Code *

Occupation *

Family Doctor

Do you have a valid driver's license? *

Yes

How did you hear about us?

Reason for your visit (check all that apply): *

routine eye exam

interested in contact lenses

headaches

double vision

night vision problems

blurred vision (near)

blurred vision (far)

blurred vision (both near and far)

broken/lost eyewear

renew contact lenses

dry eyes

eye strain

itchy eyes

OtherOther

Personal Medical History

Please check all that apply:

Acne Rosacea

AIDS/HIV

Allergies

Ankylosing Spondylitis

Anxiety

Arthritis

Asthma

Atherosclerosis

Blood Disorders

Bowel Disease

Cancer

Diabetes (Type 1)

Diabetes (Type 2)

Epilepsy

Heart Disease -Lupus

High Cholesterol

Hypertension (High Blood Pressure)

Kidney Disease

Migraine/Headache

Multiple Sclerosis

Rheumatoid Arthritis

Sarcoidosis

Stroke

Syphilis

Thyroid

Tuberculosis

OtherOther

Please list current medications:

Allergies to medications? *

Yes

Please list medications

Do you have other allergies? *

Yes

Please list:

Do you smoke? *

Yes

Personal Ocular History

When was your last visit to an optometrist? *

Less than 1 year ago

1-2 years ago

More than 2 years ago

Name of Optometrist:

Do you use a computer on a daily basis? *

Yes

How long?

periodically

1/2 of the day

all day

Have you ever worn/are you wearing contact lenses? *

Yes

What brand?

Type of contact lens solution used?

Have you ever had eye surgery? *

Yes

What type? *

muscle

cataract

refractive (PRK/LASIK)

glaucoma

eyelid

retinal

trauma

OtherOther

What was the name of the eye surgeon who performed your surgery?

Have you ever had an eye injury? *

Yes

Please describe:

Have you or a family member had any of the following eye problems/diseases? *

Glaucoma

Amblyopia ('Lazy Eye')

Turned Eye (Strabismus)

Macular Degeneration (AMD)

Retinal Detachment

Diabetic Retinopathy

Eye Patching

Cataracts

Blindness

None of the above

OtherOther

Please specify which of your family members had the problem/disease:

Signature

Clear

Today's Date:

If you are human, leave this field blank.

GLASSES :: CONTACTS :: ANNUAL CHECKUPS

Get in Touch!

(613)507-0077

info@visionaryeyecare.ca

Monday - Wednesday & Friday
8:30 AM - 5:30 PM

Thursday
10:00 AM - 7:00 PM

Saturday/Sunday
closed

1758 Bath Road, Unit 1
Kingston, Ontario, Canada
K7M 4Y2

Patient Intake Form

Clearer vision for a better life.

REQUEST AN APPOINTMENT

ORDER YOUR CONTACTS

Please fill in this form before your first visit to our office as a patient.

Personal Medical History

Personal Ocular History

Get in Touch!

(613)507-0077

info@visionaryeyecare.ca

Visionary Eyecare