Your Name*

First Last

What is the reason for your visit with us?*

Routine

What changes have you noticed to your vision, if any?*

How long has it been since your last eye exam?*

What is your occupation?*

How many hours of screen time do you get in a day? (Computer, cellphone, tablet)*

What kind of recreational activities or hobbies do you enjoy? (Reading, sports, arts, music, gaming, etc)*

Do you wear glasses?*

Yes
No
Sometimes

Do you wear contacts?*

Yes
No
Interested

What type of contacts do you wear, if any?*

Are you able to provide any additional details on your contacts? (Brand, BC, Power)*

Do you wear sunglasses outside?*

Always
Most of the time
Sometimes
Never

Are you being monitored for any medical conditions? Please list:

Do you take any medications, vitamins, or supplements? Please list:

Do you have any allergies? (Medications or environmental) Please list:

Do you smoke?*

Does anyone in your family have the following conditions? (Parents, grandparents, siblings, children)

High Blood Pressure
Thyroid issues
Heart disease
Auto immune disease
Diabetes

Do you have any eye conditions or eye disease? Please list:

Have you had any eye surgeries? Please list:

Does anyone in your family have any eye diseases or eye conditions? (Parents, grandparents, siblings, children) Please list:

Have you been experiencing any difficulty with headaches recently? If so, how often do they occur?

The following must be answered before entering the premises. In the last 14 days have you experienced any of the following?

Fever*

Yes
No

Cough*

Yes
No

Difficulty breathing*

Yes
No

Conjunctivitis/red eye or loss of taste or smell*

Yes
No

Travelled out of Canada*

Yes
No

Had contact with someone who has travelled outside of Canada*

Yes
No

Had contact with someone who is COVID-19 positive or is currently being tested for*

Yes
No

Please note the following changes to our procedures until otherwise directed by the Alberta College of Optometrists:

- We must keep our doors locked to better control patient flow through the gallery
- When you arrive please call to notify us of your arrival
- Upon entering the premises everyone will be asked to use hand sanitizer, or if you prefer we can provide hand soap and water to wash your hands
- Everyone over the age of 2 will be required to wear a mask for the duration of your stay, bringing your own mask is strongly encouraged. People who need to be asked 3 times to place their mask back on will be asked to rebook their visit to a later date when masks will no longer be required. We do give an opportunity to take favorite frames outside where there is adequate space for patients to try on without a mask.
- We ask to please be mindful of the 6 feet physical distancing measures when possible.

Please note we do offer the first appt of every day to elderly or immunocompromised patients on request.

We are providing a safe place for our immunocompromised patients and please ask everyone to be respectful of the regulations imposed on us for the duration of this Pandemic.

What is your preferred method of contact?*

Text
Email
Phone

Do you give us permission to contact you electronically?

For appointments reminders, glasses or contact orders and recalls
For sales and marketing information (we send these out 2-4 times per year)

Email Address*

Phone Number*

Signature*

By clicking this box I declare that all of the information on this page is true and accurate to the best of my knowledge.*

Intake Form – to fill out once appointment has been booked

Eye Q Optometry