Patient Questionnaire Thank you for taking a few minutes to complete this questionnaire. The information you provide will help us better understand your vision care needs and help create the perfect solution to your visual needs.Name First Last OccupationWhat activities / hobbies do you engage in?Are you interested in new glasses today?(Required) Yes No Do you use eye drops?(Required) Yes No Are you interested in lenses that change shade based on lighting conditions?(Required) Yes No Do you have to blink often?(Required) Yes No Have you worn contact lenses in the past?(Required) Yes No Are your eyes sometimes red?(Required) Yes No Have you stopped wearing them?(Required) Yes No Are you interested in the healthiest contact lenses for your eyes?(Required) Yes No Have you ever wished you could see clearly without glasses or contacts?(Required) Yes No Have you ever been diagnosed w/ rosacea?(Required) Yes No Have you ever been diagnosed with dry eyes?(Required) Yes No Do you ever feel your eyes? Ex. Most people don't feel their elbows unless they are hurt. So, do you ever 'feel' your eyes?(Required) Yes No Check all that apply Are you bothered by glare at night? Are you bothered by glare on a computer? Are you bothered by glare on sunny days? Have you ever felt your glasses were too thick? Have you ever felt your glasses were too heavy? Age-Related Macular Degeneration (AMD) Risk & Symptom Assessment AMD is the leading cause of vision loss among older Americans. It is a progressive condition that causes a part of your retina called the macula to deteriorate with age. The macula is responsible for your central vision, which allows you to do things like read, watch TV, recognize faces and drive. Check all that apply 50 years of age or older Current or past smoker Family history of macular degenration Overweight Caucasian (White) High disease, high blood pressure and/or high cholesterol Do you have? Difficulty seeing at night Difficulty reading in dim light Distorted/blurry vision Recent changes in vision Δ
