Patient Intake (Adult) Name* First Last DOB Date Format: MM slash DD slash YYYY Name of Spouse/Emergency Contact*Health ID #Phone*OccupationCheck off all that apply: COVID-19 Related Symptoms Coughing Sneezing Fever Self Glaucoma Cataracts Crossed/Lazy Eye Macular Degeneration Retinal Detachment Blindness Ocular Trauma/Foreign Body Ocular Surgery/Lasik Colour Blindness Hypertension Heart Problem Stroke Thyroid Condition Asthma Allergies HIV/ Hepatitis Cancer Neuromuscular/MS Cholesterol Diabetes Inflammatory Bowel Disorder Arthritis/ Automimmune Family Glaucoma Cataracts Crossed/Lazy Eye Macular Degeneration Retinal Detachment Blindness Ocular Trauma/Foreign Body Ocular Surgery/Lasik Colour Blindness Hypertension Heart Problem Stroke Thyroid Condition Asthma Allergies HIV/ Hepatitis Cancer Neuromuscular/MS Cholesterol Diabetes Inflammatory Bowel Disorder Arthritis/ Automimmune TypeTypePlease check all that apply Blurry distance Vision Poor Night Eye Strain Blurry Near Vision Trouble reading Itchy eyes Discharge Watering Pain in Eye Burning eyes Sandy or Dry Eye Red eyes Glare/ Reflections/Halos Rainbows around the eyes Discomfort in brightness/sunlight Double vision Floaters or spots in vision Flashes of light Dark spots in vision Headaches/Migraines Dizziness Smoker?YesNoHow longAlcoholDrinks per dayRecreational DrugsAllergiesHead Injury/Concussion?Family Doctor/GPContact Lenses?How did you hear of us?Do you use Eye DropsYesNoType of Eye DropsMedications