Triage Form PDF WORD DOC You can download the forms from one of the above files or fill out the form below. Name Date Time Email Birth Date Primary Contact Cell Landlline Please describe your concern: When did it start? Any Change? Better Worse Same Which Eye? Right Left Both Onset? Sudden Gradual Have you initiated treatment? Yes No If yes, what? Contact-lens use? Yes No If yes, do you wear contacts while asleep? Yes No Recent Eye Surgery? Yes No Or Eye Injury Yes No It's happened before? Yes No Check all that apply: Vision Problem? Yes No If yes, noticed when looking... Far Near Both Double vision? Light sensitivity? Light flashes? New/more spots in vision? Eye(s) are red? Watery eye(s)? Goupy discharge from eye(s)? Colour? Something in eye(s)? Burning? Itch? Pain? New onset headache? Please describe the severity of any of the symptoms experienced (a sacle of 0-10 can be used, zero being no symptom, and ten being the most severe symptom that you could imagine): Any other relevant info? Send
