Medical History Medical History and Needs Form Due to COVID-19, to ensure a safe and efficient visit with Freelton Eye Care, we ask that you complete and submit this form within 2 business days to guarantee your appointment. *If a question does not apply to you or you are unsure of the answer, indicate “N/A” or “unsure”; DO NOT LEAVE BLANK!1. PATIENT INFORMATIONName (as it appears on your health card) Preferred Name Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (H)Phone (C)*Email address Do you consent to Freelton Eye Care emailing to correspond with you regarding your health care, as well as upcoming events and promotions? Yes No *For questions regarding anti-spam legislation, go to crtc.gc.ca/eng/com500/faq500.htmPreferred Method of Contact Text Call Email OHIP:HEALTH CARD: # Version Code Expiry Date MM slash DD slash YYYY 2. MEDICAL HISTORY and VISUAL NEEDSLast Eye Exam (approximate month/year) Reason for visit? Any vision changes since your last exam? Any recent eye strain? Yes No If yes, please describe:Health Conditions/Medications (dosage NOT needed)?Drug or LATEX Allergies? Family Doctor? Last Check-up? Eye Conditions, Eye Diseases, or Eye Surgeries?Currently using Eyedrops (name(s) & how often)? Eye Diseases that run in your FAMILY? If yes, state disease and relationship of the individual to you.Do you wear glasses? Yes No If yes, when? Watching TV Driving Computer Small Print Hobbies For Sun Protection All the time How often are you on the computer? 1-5 hours/week 6-20 hours/week Over 20 hours/week Do you wear contact lenses? Yes No If yes, what kind? Check all that apply Dailies? Monthlies? Rigid Gas Permeable? Scleral? Overnights? Multifocals? If applicable, rate the comfort level of your current contacts on a scale from 1 to 10Do you plan to order any products at the time of your visit? Yes No If yes, please check all that apply: Eyeglasses Contact lenses Eyedrops Vitamins Other Other COVID-19Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing? Yes No Have you had close contact with anyone with an acute respiratory illness? Yes No Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case? Yes No Have you travelled outside of Canada in the past 14 days or been in contact with someone who has travelled and sick in the past 14 days? Yes No Are you experiencing any delirium, unexplained falls, acute functional decline or recent worsening of chronic conditions? Yes No If you answered “Yes” to any of these questions, please explainIf you are NEW to the office, please tell us how you heard about us.Please bring to your exam insurance benefit card current glasses/sunglasses contact lenses mask or equivalent face cover OHIP covers the BASIC elements of an eye examination. Freelton Eye Care uses advanced diagnostic testing NOT covered by OHIP to detect and manage eye disease earlier and more precisely, resulting in better health outcomes. These diagnostic services include Visual Field Screening & Analysis; Optical Coherance Tomography (OCT-Disc and/or Macula) & Analysis; and Baseline Fundus Photography. By signing this form, you consent to Freelton Eye Care’s collection of the information above. We collect, use and share your personal information for the following purposes: your ongoing eye care; to provide services to you; to understand your eligibility for benefits and/or services; to arrange payment for services, and as required by law. The collection of this information is authorized by the Health Insurance Act, Optometry Act, Regulated Health Professions Act and Health Protection and Promotion Act. We will take ALL possible steps to ensure that your personal information is treated confidentially and to prevent unauthorized access, use or disclosure of your personal information. Providing my insurance card information to enable Freelton Eye Care to bill directly for my visit and accept payment on your behalf, when applicable. Accepting payment receipts and glasses prescriptions via email. Providing my personal health information to ensure the time I spend in the office is efficient and focused on my medical care. Application of a $100 charge on the officially-booked appointment date if I do not attend my appointment OR cancel with fewer than 2 business days’ notice. I, have read the information on this form and DO CONSENT to the above.Name First Last SignatureDate MM slash DD slash YYYY
In case of emergency, please phone our office at the number listed above. After hours, please visit your nearest emergency room.