Medical History Returning Patients 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 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 Consent- this only applies for those covered by OHIP for their eye examOHIP 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 $45 No Yes Do you wish to have an Optical Coherence Tomography (OCT) performed $80 No Yes Do you wish to have both Digital Retinal Imaging and OCT performed $105 No Yes Medical HistoryHave there been any changes in your allergies or medications? No Yes If Yes, list medication(s) and/or allergies and reaction below:Include Name of Medication, Dosage, Frequency Taken etc...Have you experienced any changes in your vision since your last visit?Are you pregnant or nursing? No Yes Patient Signature PhoneThis field is for validation purposes and should be left unchanged.