Your Name*

First Last

Do you have any specific concerns you want to address during your eye exam?*

Do you wear glasses?*

Do you wear contact lenses?*

Can you let us know what type of contacts you currently wear?*

Do you wear sunglasses outside?*

Noticing any changes in your vision?*

Do you have any visually demanding hobbies or interests? (Reading, sports, arts, music)*

Do you get Headaches? Have trouble focusing?*

What is your occupation?*

How many hours/day of screen time do you have? (computer, cell phone, tablet)*

Do you have any eye conditions or eye disease?*

Have you had any eye surgeries?*

Are you being monitored for any medical conditions?*

Do you take any medication, vitamins or supplements?*

Do you have any allergies?*

Do you smoke?*

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

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

Diabetes
High Blood Pressure
Thyroid issues
Heart disease
Auto immune disease

The following must be answered before entering the premises. In the last 14 days have you experienced anything in the box below? Please indicate yes or no.*

- Fever
- Cough
- Difficulty breathing
- Conjunctivitis/red eye
- Sudden loss of smell
- GI upset
- Travelled out of Canada
- Had contact with someone who has travelled outside of Canada
- Had contact with someone who tested positive for COVID-19 or currently being tested for COVID-19

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 5 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*

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