Patient's Name

First Last

GENERAL VISUAL DISCOMFORT

*I am concerned about….*

Night Vision
Sunshine
Computer Glare
Difficulty reading or doing fine print work?
Difficulty reading computer or at arms length?
Difficulty seeing street signs/T.V.?

EYEWEAR

Are you satisfied with the way your glasses look/feel?

Are you satisfied with the vision/comfort?

Do you wear sunglasses/Polarized?

I AM INTERESTED IN

No line Bifocals (Progressives)
Sunglasses/Polarized
Lenses to Reduce Glare (Anti-Reflective)
Lighter, Thinner Lenses (Polycarbonate)
Self-darkening Lenses (Transitions)
Contact Lenses

OCCUPATIONAL NEEDS/HOBBIES

What is your occupation?

How many hours a day are you on digital devices?

Do you work with solvents, paint, dust, or welding?

Outside?

What are your hobbies/sports?

How many hours do you drive daily?

How does light bother you?

What times would you like to NOT wear your glasses?

CONTACT LENS QUESTIONNAIRE

What brand contact lenses do you wear?

How old is this pair?

How often do you change out your lenses (for new pair)?

Do you sleep in your contacts?

Yes
No

If yes, how many nights/row?

What brand contact lens solution do you use?

Patient Signature:

Date

Located in NW Phoenix near Bell Road & 43rd Ave.

LIFESTYLE AND CONTACT LENS QUESTIONNAIRE

GENERAL VISUAL DISCOMFORT

EYEWEAR

OCCUPATIONAL NEEDS/HOBBIES

CONTACT LENS QUESTIONNAIRE

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Testimonials

Advanced Eye Care Center

Located in NW Phoenix near Bell Road & 43rd Ave.

GENERAL VISUAL DISCOMFORT

EYEWEAR

OCCUPATIONAL NEEDS/HOBBIES

CONTACT LENS QUESTIONNAIRE

Follow Us

Testimonials

My experience was fantastic!!!

Dr Johnson is so great

The staff is awesome and Dr. Johnson is wonderful!

Great eye care center!

I am so happy and very impressed.

Advanced Eye Care Center