Name: (Required) Address:
City:

Province: Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland and Labrador (NL) Northwest Territories (NT) Nova Scotia (NS) Nunavut (NU) Prince Edward Island (PE) Saskatchewan (SK) Ontario (ON) Quebec (QC) Yukon (YT)
Postal Code:
Home Phone Number: (Required) Alternate Phone Number: (Required) Care Card Number: (Required)
Birthday: (Required)  mm/dd/yy Referred by: (Required) Last eye exam: (Required)

Insurance Company Information:
If you would like us to help you with your insurance claim:

Name of Insurance Company: (Required) Policy Number: (Required) Certificate Number: (Required)

Sullivan Optometry is dedicated to improving your overall health status, and as such, we correspond frequently with our patient's family doctors.

Family Doctor's Name: (Required) Telephone Number: (Required) Address: (Required)

Medications:

Please list ALL of your current meds, prescription or non-prescription:

Health History:

What is the main reason for your appointment?
How many hours a day do you use a computer? 1 hr 0 hrs 2 hr 3 hr 4 hr 5 hr 6 hr 7 hr 8 hr More than 8 hrs

Have you had a Visual Field test done in the past? No Yes

Have you had one of the following 6 conditions? Sinus Condition Yes No
Thyroid Condition Yes No
Diabetes Yes No
Cancer Yes No
Allergies Yes No
Headaches Yes No

Oscular History:
Have you ever had:

An eye injury Yes No
An eye infection Yes No
An eye surgery Yes No
Flashes or Floaters Yes No

Family history:
Does anyone in your family have:

Glaucoma Yes No
Retinal Detachment Yes No
Crossed Eyes Yes No

This section is reserved for CONTACT LENS wearers only:

Brand name of lens: Brand name of solution: Brand name of rewetting drop: How days a week do you wear contacts 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days How many hours a day do you wear contacts? 1 Hour 2-3 Hours 4-5 Hours 6-7 Hours 8-9 Hours 10-11 Hours 12 or more Hours
How often do you throw away your lenses? How often do you sleep with your lenses? Are your CL's comfortable all day? No Yes Is your vision with your CL's clear? No Yes