OCULAR & MEDICAL HISTORY QUESTIONNAIRE

OCULAR & MEDICAL HISTORY QUESTIONNAIRE
Date

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Full Name

PrefixFirst NameMiddle NameLast Name
Date of birth

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Gender
OHIP
Version Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
Format: (000) 000-0000.
Occupation
Email Address
example@example.com
Family Doctor
Date of last eye exam

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Date of last medical exam

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
How many hours a day do you spend on electronic devices (smartphone, laptop, PC,tablet)?
How did you hear about us?
If other, please specify
Do you drive?
Hobbies
Have you ever worn or currently wear glasses?
When do you wear your glasses?
Have you ever worn or currently wear contact lenses?
What type of contact lenses?
When do you wear your contact lenses?
Are you having any trouble seeing far away or close-up?
If yes, please select
Do you suffer with frequent headaches or migraines?
Frequency of headaches or migraines
Do you ever see floaters or flashes of light?
Please select
Which eye?
Do you play any contact sports?
Have you ever had eye surgery?
What type of surgery?
If other, please specify

Do you suffer with or have you ever experienced any of the following?

Rows	Yes	No
Itchy/dry/burning/watery eyes
Red eyes
Frequent styes/infections
Light sensitivity
Double vision
Temporary loss of vision
Fluctuating vision
Halos around lights
Injury to the eyes
Injury/trauma to the head (e.g., car accident, concussion)

Please list any other symptoms you have experienced

Do you have any of the following medical conditions?

Rows	Yes	No
High blood pressure
Elevated cholesterol
Heart disease
Diabetes
Thyroid imbalance
Arthritis
Sleep apnea
Kidney problems

If diagnosed with diabetes, please specify type
If diagnosed with diabetes, please specify number of years
Please list any other medical conditions

Do you have any of the following ocular conditions?

Rows	Yes	No
Eye(s) turned in/out
Lazy eye
Cataract
Glaucoma
Macular degeneration

Any other ocular conditions, please list

Do any of your blood relatives have any of the following ocular or medical conditions?

Rows	Yes	No
Glaucoma
Cataracts
Macular degeneration
Lazy/crossed eye(s)
Retinal detachment
Keratoconus
Diabetes
High blood pressure
Heart disease
Thyroid imbalance
Cancer

Any other ocular or medical conditions in any of your blood relatives
Please list any medications and/or supplements that you are currently taking:
Do you have any allergies?
What type of allergies
Please list the allergies.
Smoking / Vaping / Cannabis Use
Tobacco (cigarettes, cigars, pipe, etc.)
If current, please describe type and frequency:
Vaping / E-cigarettes
If current, please describe type (nicotine / non-nicotine) and frequency:
Cannabis (smoked, vaped, or edibles)
If current, please describe type and frequency:
Have you been regularly exposed to secondhand smoke or vape?
Pregnancy & Breastfeeding (for female patients only)
Are you currently pregnant?
If yes, Trimester
Are you currently breastfeeding?
Insurance & Billing Information

This information helps us process your insurance claims efficiently.
Insurance Provider:
Policy Number:
Group or ID Number (if applicable):
Primary Cardholder's Name (if different):
Relationship to Cardholder:
Would you like us to bill your insurance directly (if eligible)?
Consent & Acknowledgement

Please review and confirm before submitting your form.
I confirm that the information provided above is accurate and complete to the best of my knowledge.
I consent to the collection, use, and storage of my personal health information by Dr. Irene Kokoshko Optometry Professional Corporation O/A KOKO Vision in accordance with Ontario's Personal Health Information Protection Act (PHIPA).
I understand that this information will be used to provide appropriate eye care, communicate regarding appointments and treatments, and coordinate insurance billing when applicable.
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