GENERAL VISUAL DISCOMFORT

*I am concerned about….*

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

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?

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?

If yes, how many nights/row?

What brand contact lens solution do you use?

Patient Signature:

Date