WHITBY VISION CARE 736 Dundas Street West Whitby, Ont. L1N2N4 905.666.4848 www.whitbyvision.ca DR. PAMELA SCHMTZ DR. LINDA SUJO DR. PAMELA ANDREWS DR. KETHARINI SIVASEGARAN We ask that you kindly complete all the information below. This information will greatly aid in the assessment of your vision and ocular health. I understand that my personal information is kept strictly confidential and used for the sole purpose of my examination. I also understand that I am mailed a recall notice to remind me of any future visits.SIGNED:Name: First Last Preferred Name:Address: Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email address: Yes, I consent to receiving appointment reminders, newsletters and other electronic messages from Whitby Vision Care. You may withdraw consent at any time. Home Phone:Business Phone:Cell Phone:Birth date: MM slash DD slash YYYY Do you presently wear:YesNoGlassesContact lensesFamily Doctor:Last Medical Exam: MM slash DD slash YYYY Last Eye Exam: MM slash DD slash YYYY Occupation:Hobbies:How were you referred to our office?Any history of…SelfFamilyAge Related Macular Degeneration (AMD)GlaucomaCataractsBlindnessCrossed/Lazy eyeRetinal DetachmentHeart ProblemsStrokeHigh CholesterolHigh Blood PressureSmokerArthritisThyroid DiseaseHIV/HepatitisCancerNeurological ProblemsDiabetesKidney TroubleCheck off all that apply… Eye Vitamin Supplements Blurry distance vision Blurry near vision Eye Strain Poor night vision Trouble reading Itchy eyes Discharge/Watering Halos Pain in the eye Sandy or dry eyes Double Vision Floaters/spots in vision Discomfort in brightness/sun Flashes of light An eye injury History of wearing eye patch Headaches Eye exercises Pregnant/Lactating Are you interested in…? Laser Vision Correction New glasses Magnifiers Eyeglass Value Packages Sunglasses/Clip-Ons Contact Lenses Perceptual Testing OTHER MAJOR HEALTH PROBLEMS (List) : Medications you take: Allergies: WE THANK YOU FOR COMPLETING THIS FORM Δ
