Patient History Form for Dr. Jade in Lloydminster – Register Now

At our Lloydminster eye care office, Dr. Jade asks that you complete the patient history form below. You can choose to fill it out online and submit it, or print out the form after full or partial completion and bring it when you visit the office. If you have any questions or concerns about the form, please call us.


Patient Registration Form

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Male
Female
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other
I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection
I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
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