Adult Intake Online Form ADULT INFORMATIONName 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 How did you hear about us? When was your last eye exam? Who was the eye doctor? Chief Complaint (Reason for Today’s Visit)Your Medical History Diabetes Stroke Head injury Whiplash Asthma Arthritis Thyroid Heart problems High blood pressure Other Please Specify List of Medication List of Allergies Family Eye/Medical Problems Your Eye History Glaucoma Cataracts Retinal detachment Macular degeneration Colour blindness Turned or wandering eye Eye surgery Dry eye Lazy eye Vision therapy Eye injury Do You Use Eye drops Eye Glasses Contact lenses Sunglasses Hot compresses Eye patch Magnifier Do 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 Any other comments?INSURANCE INFORMATIONPrimary InsuranceCompany Plan Member Policy Member ID Secondary InsuranceCompany Plan Member Policy Member ID Additional InformationHead injury/stroke/otherDate of loss MM slash DD slash YYYY Car accident Stroke Concussion Tests/Treatments CT scan MRI Physiotherapy Craniosacral therapy Chiropractic Hospitalization Other Please Specify Eye-Hand Coordination Poor hand writing Difficulty reaching for objects Reverses/ omits letters Difficulty catching balls Driving Do not drive Valid driver’s license License is now suspended Trouble judging distances Blur Headache Eye strain TV/ Distance Vision Blur Double Eye strain Too bright Squinting Trouble judging distances Other Please Specify Lighting and Glare Sensitivity in sun Sensitivity on cloudy days Sensitivity in office/stores Sensitivity in home Sensitivity at night Other Please Specify Reading Lose place Skip or re-reading lines Holds book close Print swims or moves Eye strain Poor comprehension Forgets what is just read Other Please Specify Working/WorkWhere do you work Please explain work done before the loss and after the loss. Include when or if you expect to return to work. Explain why you cannot work or if your work is limited. Academic/School Do not go to school In school Please explain any difficulties