Patient History Form Welcome to Century Vision Care. We aim to address and fulfill all of your eye care needs. By completing this form, you will assist us in personalizing a comprehensive eye exam. Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* Date Format: MM slash DD slash YYYY AgeParent/Guardian (If under 18 years)Alberta Health Care #*OccupationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HomeCellWorkEmail Preferred Method of Contact* Text Email Home Cell Work Have you ever seen Dr. Lopetinsky for an eye exam before?*YesNoVision Insurance* Blue Cross Great West Life Sunlife Greenshield RCMP None Other OtherReason for Today's Visit* Routine Diabetic Health Exam Other Approximate Date of Last Eye Exam?*Do you currently wear Glasses?* Yes No Do you currently wear Sunglasses?* Yes No Do you currently wear Contact Lenses?* Yes Dailies Monlthy Other NO If yes, please take a picture or bring in the boxes of your most recent supply. Are you interested in contact lenses today?* Yes No Have you ever had Cataract Surgery?SelectYesNoWhen and which Doctor?Any other eye Surgery?SelectYesNoPlease explain:List any eye drops you currently use:Medical and Ocular History(Please check all that apply)CataractsSelfFamilyGlaucomaSelfFamilyLazy EyeSelfFamilyIritis/UveitisSelfFamilyRetinal DetachmentSelfFamilyMacular DegenerationSelfFamilyKeratoconusSelfFamilyDiabetesSelfFamilyHeart DiseaseSelfFamilyThyroidSelfFamilyHigh Blood PressureSelfFamilyOther(Please List)Who is your Family Doctor?Current Medications AllergiesWho can we thank for referring you?Today's Date Date Format: MM slash DD slash YYYY Ask about our 'Referral Rewards Program'