Patient Intake Form

Please fill in this form prior to your appointment.

Fields with a red * are required

2232 West 4th Avenue Vancouver, BC V6K 1N7
P: 604-732-6060
F: 604-357-1920
E: eyeexams@hush.com

We are delighted to be seeing you for your eye examination. Although a COVID safety plan is no longer required, examinations will be performed with both doctors and patients wearing PPE. When possible relevant information and exam history will be collected before your examination to minimize time spent in close proximity. The patient schedules will be adjusted to reduce the number of patients in the office and to allow all equipment to be thoroughly disinfected between patients. Physical protective plexiglass barriers have been added to the examination equipment where possible.

Accepted forms of payments are debit and credit cards only.

Please fill in the following form.

Personal Information

First Name

Middle Name (s)

Last Name

Apartment Number

Street Address

City

Postal Code

Cell Phone Number

Email address

Date of Birth

Care card or MSP number

Can be found on your BC services card or on the back of your BC driver's license ( e.g 9020 517 720 )

How did you hear about us?

Walk By Patient Referral Dr. Mehin's Previous Patient Bailey Nelson

Eye Exam History

What is prompting your visit?

Routine eye care Urgent eye care Pink or Red eye Other

Explain in the space below

When was your last eye exam ?

Where was your last eye examination?

Please indicate if you would like us to arrange to obtain records from your previous doctor

Yes No

If yes, please list the eye care provider

Glasses history

List the type of glasses you currently own?

All the time Mostly for distance Mostly for near Mostly for computer use Progressives Bifocal or Trifocals None Sunglasses

Lifestyle Questions

Occupation

Hobbies

Eye Health History

Are you using any eye drops ?

Yes No

Please list which drops.

Please check have had any of the following dry eye related eye problems.

Eye Discomfort

Dry Eyes

Tearing or Watery Eyes

Excessive Screen Time

Contact lens Failure due to Dry Eyes

Take the DEQ-5 Dry Eye Questionnaire

We invite you to take the DEQ-5 dry eye screening if you checked any of the above dry eye symptoms

Questions about EYE DISCOMFORT: During a typical day in the past month, how often did your eyes feel discomfort?

Rarely (1) Sometimes (2) Frequently (3) Constantly (4)

Questions about EYE DISCOMFORT: During a typical day in the past month, how often did your eyes feel discomfort?

Not intense at all (1) Somewhat intense (2) Intense (3) Very Intense (4) Extremely Intense (5)

Questions about EYE DRYNESS: During a typical day in the past month, how often did your eyes feel dry?

Rarely (1) Sometimes (2) Frequently (3) Constantly (4)

Questions about EYE DRYNESS: During a typical day in the past month, how often did your eyes feel discomfort?

Not at all intense (1) Somewhat intense (2) Intense (3) Very intense (4) Extremely intense (5)

Questions about Watery Eyes: During a typical day in the past month, how often did your eyes feel excessively watery?

Never Rarely (1) Sometimes (2) Frequently (3) Constantly (4)

Family Eye Health History

Do any of your family members have the following? Check the conditions which apply

Glaucoma

Cataracts

Macular Degeneration

Lazy Eye

Other

If yes, name the condition and who has it

Past Medical History

List your clinic or family physician

List any medical conditions you have including diabetes, thyroid, autoimmune or other

List all prescription medications or anything over the counter you take.

Do you have any allergies? Including medications, foods or environmental allergies.

Contact Lens History

Do you use contacts currently? Ask your optometrist about updating your parameters ( Additional Fees Apply)

Yes No

Have you used contact lenses in the past?

Yes No

Are you interested in becoming a new wearer or using contact lenses again? Ask your optometrist about this ( Additional Fees Apply)

Yes No

Describe your contact lens use

Rare Full time Part time Only for sports

What type of contact lenses do you use?

Spherical Toric/Astigmatic Multi or Bifocal Monovision Not sure

How often do you replace your lenses ?

Dailies Two week Monthly Extended wear (eg overnight use)

Please indicate which contact lens solution you use

Biotrue Optifree Clear Care Solo Renu B & L Sensitive Other or generic

Your information will be encrypted.

Patient Intake Form

Please fill in this form prior to your appointment.

Personal Information

Eye Exam History

Glasses history

Lifestyle Questions

Eye Health History

Take the DEQ-5 Dry Eye Questionnaire

Family Eye Health History

Past Medical History

Contact Lens History

Please fill in this form prior to your appointment.

Dr. Mitra E. Mehin BSC, OD, FAAO

Doctor of Optometry