Eye Care Questionnaire

We will email your results to you.

Name

First Name

Last Name

Would you say your eyesight (with glasses or contacts, if you wear them) could be improved?

Do you have, or have you had, pain or discomfort in and around your eyes?

Do you have difficulty reading ordinary print?

Do you have difficulty going down stairs and steps?

Do you have difficulty in noticing objects off to the side while walking alone?

Do you see halos or starbursts while driving at night?

Do you accomplish less than you would like because of your vision?

Are you limited in how long you can work, or do other activities, because of your vision

Has you vision changed in the past year?

If you are over 40, do you have an annual dilated eye exam?

Do you have a family history of glaucoma, diabetes or macular degeneration?

Have you ever considered LASIK?

Ready to get in touch?

We’d love to discuss your needs and how we can help.