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39 Commerce Rd, Lindsay ON
(705) 320-8001
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Refractive Questionnaire
Name
First
Last
Email Address
How did you hear about LASIK CATARACT CENTRE?
How did you hear about LASIK CATARACT CENTRE?
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Optometrist Referral
Online Search
Friend
Other…
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Optometrist
Date Last Seen
Contact Lenses
- None -
Soft
Hard
Date Last Worn
Occupation
Hobbies/Sports
Medical Conditions
Are You Currently Pregnant?
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Yes
No
Diabetes
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Yes
No
Rheumatoid arthritis, Lupus, HIV, Hepatitis, any autoimmune condition
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Yes
No
Cancer, or other condition suppressing immune system
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Yes
No
Multiple sclerosis
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Yes
No
Eye Conditions
Amblyopia(lazy eye)
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Yes
No
Herpes Simplex (cold sore on the eye) or Herpes Zoster (shingles on the eye)
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Yes
No
Keratoconus or any corneal disease
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Yes
No
Dry eyes
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Yes
No
Cataract
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Yes
No
Glaucoma
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Yes
No
Previous Eye Trauma
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Yes
No
Eye Trauma Details
Other
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Yes
No
Other Details
Previous eyes surgery
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Yes
No
Medications (please list)
Allergies
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