Name: Eye Health Centre
Address: 114-506 St. Albert Trail, St. Albert, AB, T8N 5Z1, CA
Telephone: 780-419-7000
Price range: $000 - $300

Please fill out the questionnaire carefully before your appointment. The time spent answering questions will allow the doctor to better plan the flow of the examination procedures.

Thank you for your time and effort in completing this questionnaire. Leave blank or put N/A besides questions that do not apply.

Step 1 of 7 - PATIENT INFORMATIONS

PATIENT INFORMATIONS
Patient Name
First Last
Gender
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Occupation
Address
Street Address Address Line 2 City Province Postal Code
Alberta Health Care Number
Phone
Email
Who referred you to Eye Health Centre?
Date
MM slash DD slash YYYY

	Never	Seldom	Occasionally	Frequently	Always
Blurred close vision
Double vision
Headaches with near work
Words run together reading
Burning, itchy, watery eyes
Falls asleep reading
Sees worse at the end of day
Skips/repeats lines reading
Dizzy/nauseated by near work
Head tilt/one eye closed to read
Difficulty copying from board
Avoids near work/reading
Omits small words when reading
Writes uphill/downhill
Misaligns digits/columns of numbers
Poor reading comprehension
Poor/inconsistent in sports
Holds reading too close
Trouble keeping attention on reading
Difficulty completing work on time
Says "I can't" before trying
Avoids sports/games
Poor hand/eye coordination
Poor handwriting
Does not judge distance accurately
Clumsy, knocks things over
Poor time use/management
Does not make change well
Loses things/belongings
Car or motion sickness
Forgetfulness/poor memory

Adult Questionnaire

Step 1 of 7 - PATIENT INFORMATIONS

PATIENT INFORMATIONS

PRESENT SITUATION AND SYMPTOMS

VISUAL HISTORY

MEDICAL HISTORY

QUALITY OF LIFE CHECKLIST

COMPUTER

HOBBIES/SPORTS

EMPLOYMENT OR SCHOOL