OCULAR & MEDICAL HISTORY QUESTIONNAIRE

Date

Full Name*

Prefix First NameMiddle NameLast Name

Date of birth*

Date

Gender*

OHIP*

Version Code*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Number*

Occupation

Email Address*

example@example.com

Family Doctor*

Date of last eye exam

Date

Date of last medical exam

Date

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?*

YesNo

Hobbies

Have you ever worn or currently wear glasses?*

YesNo

When do you wear your glasses?*

Have you ever worn or currently wear contact lenses?*

YesNo

What type of contact lenses?*

When do you wear your contact lenses?*

Are you having any trouble seeing far away or close-up?*

YesNo

If yes, please select*

Do you suffer with frequent headaches or migraines?*

YesNo

Frequency of headaches or migraines*

Do you ever see floaters or flashes of light?*

YesNo

Please select*

Which eye?*

Do you play any contact sports?*

YesNo

Have you ever had eye surgery?*

YesNo

What type of surgery?*

If other, please specify*

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

	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?*

	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?*

	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?*

	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?*

YesNo

What type of allergies*

Please list the allergies.*

Smoking / Vaping / Cannabis Use

Tobacco (cigarettes, cigars, pipe, etc.)*

NeverFormerOccasional / SocialCurrent

If current, please describe type and frequency:

Vaping / E-cigarettes*

NeverFormerOccasional / SocialCurrent

If current, please describe type (nicotine / non-nicotine) and frequency:

Cannabis (smoked, vaped, or edibles)*

NeverFormerOccasional / SocialCurrent

If current, please describe type and frequency:

Have you been regularly exposed to secondhand smoke or vape?*

YesNo

Pregnancy & Breastfeeding (for female patients only)

Are you currently pregnant?

NoYes

If yes, Trimester

Are you currently breastfeeding?

NoYes

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)?

YesNo

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.*

Yes.

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).*

Yes.

I understand that this information will be used to provide appropriate eye care, communicate regarding appointments and treatments, and coordinate insurance billing when applicable.*

Yes.

Signature*

form_phipa