Adult Intake Online Form New Patient FormName First Last M F Date of Birth MM slash DD slash YYYY Health Card # VC Home 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 Home PhoneCell PhoneEmail Address HiddenHow did you hear about us? When was your last eye exam? HiddenWho was the eye doctor? Reason for Today’s VisitHiddenYour Medical History Diabetes Stroke Head injury Whiplash Asthma Arthritis Thyroid Heart problems High blood pressure Other HiddenPlease Specify HiddenList of Medication HiddenList of Allergies HiddenFamily Eye/Medical Problems HiddenYour Eye History Glaucoma Cataracts Retinal detachment Macular degeneration Colour blindness Turned or wandering eye Eye surgery Dry eye Lazy eye Vision therapy Eye injury HiddenDo You Use Eye drops Eye Glasses Contact lenses Sunglasses Hot compresses Eye patch Magnifier HiddenDo You Currently Have Trouble seeing distance Trouble reading Blur Head aches Achy eyes Light sensitivity Dry eyes Red eyes Watering eyes Itchy eyes Tired eyes Burning eyes Double vision Flashes Spots Discharge from eye Nausea Dizziness Trouble losing belongings (keys, etc) Poor memory/forgetful Poor concentration/ easily distracted HiddenAny other comments?INSURANCE INFORMATIONPrimary InsuranceCompany Plan Member Policy Member ID Secondary InsuranceCompany Plan Member Policy Member ID HiddenAdditional InformationHead injury/stroke/otherHiddenDate of loss MM slash DD slash YYYY Hidden Car accident Stroke Concussion HiddenTests/Treatments CT scan MRI Physiotherapy Craniosacral therapy Chiropractic Hospitalization Other HiddenPlease Specify HiddenEye-Hand Coordination Poor hand writing Difficulty reaching for objects Reverses/ omits letters Difficulty catching balls HiddenDriving Do not drive Valid driver’s license License is now suspended Trouble judging distances Blur Headache Eye strain HiddenTV/ Distance Vision Blur Double Eye strain Too bright Squinting Trouble judging distances Other HiddenPlease Specify HiddenLighting and Glare Sensitivity in sun Sensitivity on cloudy days Sensitivity in office/stores Sensitivity in home Sensitivity at night Other HiddenPlease Specify HiddenReading Lose place Skip or re-reading lines Holds book close Print swims or moves Eye strain Poor comprehension Forgets what is just read Other HiddenPlease Specify Working/WorkHiddenWhere do you work HiddenPlease explain work done before the loss and after the loss. Include when or if you expect to return to work. HiddenExplain why you cannot work or if your work is limited. HiddenAcademic/School Do not go to school In school HiddenPlease explain any difficulties