Medical History and Needs Form Due to COVID-19, our office procedures have been enhanced for your safety. To ensure a safe and efficient visit for you, we require that you complete and submit this Medical History and Needs Form in the next 48 hours to guarantee your appointment. Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Number*Please provide a telephone number, with area code, so we can contact you. Cell PhoneWork PhoneEmail AddressPlease provide your email address. Employer Occupation Date of Birth* MM slash DD slash YYYY Preferred Language Gender Female Male Who may we thank for referring you to our office? Date of Last Medical Exam Name of Medical Doctor Doctor's Phone Number Date of Last Eye Exam Spouse or Guardian (If Applicable) Covid -19 QuestionnaireDo you have fever, new cough, worsening of chronic cough, shortness of breath, or difficulty breathing No Yes Do you have close contact with anyone with respiratory illness or travel outside of Canada in last 14 days No Yes Do you have confirmed case of covid-19 or had close contact with a confirmed case No Yes Do you have Two or more of the following symptoms: sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, impaired sense of smell, chills, headaches, fatigue, diarrhea, abdominal pain, or nausea/vomiting. No Yes If over 65 yrs of age do you have delirium, falls, worsening of chronic condition No Yes Fee ConsentOHIP covers the basic elements of an eye examination. Dr Kingstone uses advance diagnostic testing not covered by OHIP (Digital retinal imaging and Ocular Coherence Tomography (OCT)) to detect and manage retinal eye disease earlier and more precisely, resulting in better health outcomes. It is highly recommended that all patients take advantage of these procedures in addition to their regular eye exam. Please note: this only applies to those who are covered for their regular eye exam through OHIPDo you wish to have Digital Retinal Imaging performed $40 No Yes Do you wish to have an Ocular Coherence Tomography (OCT) performed $75. No Yes Do you wish to have both an OCT and a Digital Retinal Imaging performed $95. No Yes Medical HistoryDo you have any allergies to medications? No Yes If Yes, list medication(s) and reaction below:List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:Include Name of Medication, Dosage, Frequency TakenList all major injuries, surgeries and/or hospitalizations you have had:Check any of the following that you have had: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Cataracts Glaucoma Iritis/Uveitis Macular Degeneration Retinal Disease of Detachment Eye Infections Eye Injury Corneal Problems Other Eye Disorders If Other Eye Disorders, please explain: Are you pregnant or nursing? No Yes Do you wear glasses? No Yes If Yes, how old is your present pair of lenses? Do you wear contact lenses? No Yes If Yes, how old is your present pair of lenses? Type of Contact Lenses: Rigid Soft Extended Wear Other Are they comfortable? No Yes Family HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.Disease/Condition Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment or Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Thyroid Disease Other If Other, please explain:If Yes to any of the above, please explain:REVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?NeurologicalHeadaches No Yes Migraines No Yes Seizures No Yes EyesLoss of Vision No Yes Blurred Vision No Yes Distorted Vision/Halos No Yes Loss of Side Vision No Yes Double Vision No Yes Dryness No Yes Mucous Discharge No Yes Redness No Yes Sandy or Gritty Feeling No Yes Itching No Yes Burning No Yes Foreign Body Sensation No Yes Excess Tearing/Watering No Yes Glare/Light Sensitivity No Yes Eye Pain or Soreness No Yes Chronic Infection, Eye or Lid No Yes Styes or Chalazion No Yes Flashes/Floaters in Vision No Yes Tired Eyes No Yes RespiratoryAsthma No Yes Chronic Bronchitis No Yes Emphysema No Yes Vascular/CardiovascularDiabetes No Yes Heart Pain No Yes High Blood Pressure No Yes Vascular Disease No Yes Bones/Joints/MusclesRheumatoid Arthritis No Yes Muscle Pain No Yes Joint Pain No Yes If you answered Yes to any of the above or have a condition not listed, please explain and list medications:Patient Signature Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.