Your Name (required)

Date of Birth (required)

Phone Number (required)

Your Email (required)

Your Address

Your Medical Doctor

Your Private Health Insurance NoneAlberta Blue CrossGreenshieldCanadaLife (formerly Great West Life)DesjardinsManulifeSunlifeOther

Do you currently wear glasses? YesNo
If so what for? Distance/ DrivingReadingBoth

Do you wear contact lenses? YesNo
How frequently do you change them? DailyWeekly2 WeeklyMonthly
Contact Lens Name

Do you use eye drops? YesNo
If so, what kind?

Primary reason for upcoming exam

Do you have any of the following
Blurry VisionDry EyesItchy EyesTired EyesDouble VisionFlashesFloatersEye InjuriesEye Surgeries

Your Medications - if none, please write 'none'

Any Allergies? If so please list, if none, please write 'none'

Medical History, please mark all that apply
AmblyopiaArthritisBlindnessBrain TumourCancerCataractsCornea ProblemsCorneal TransplantCrossed/Lazy EyeDetached RetinaDiabetesEpilepsy/SeizuresGlaucomaHeart ProblemsHigh Blood PressureKeratoconusKidney ProblemsLearning DisabilityMacular DegenerationMultiple SclerosisNoneStrokeTuberculosisTraumatic Brain InjuryThyroid Condition

Are you seeing an ophthalmologist?
YesNo
Ophthalmologist Name
Office Name and Phone Number

Do you smoke cigarettes?
NeverOccasionallyFrequently

Are you pregnant or nursing?
YesNo

On average, how much time do you usually spend in front of a computer?
NeverLess than an hour1-4 hours4-8 hoursOver 8 hours