ARE YOU BETWEEN THE AGES OF 18 AND 55?

yes

no

WHAT IS YOUR OCCUPATION?

HAVE YOU HAD PRIOR EYE SURGERY?

yes

no

WHEN DID YOU START WEARING GLASSES?

Under 40

40-55

Over 55

HAVE YOU NOTICED DETERIORATION OF YOUR VISION IN THE LAST FIVE YEARS?

yes

no

ARE YOU RECEIVING NEW GLASSES PRESCRIPTIONS OFTEN BUT IT DOESN’T SEEM TO HELP ENOUGH?

yes

no

PLEASE SELECT ALL CHANGES IN YOUR VISION THAT APPLY:

Blurry or cloudy vision

Halos and lights/light sensitivity

Poor vision at night

Double vision

Colors less vibrant

None of the above

WHAT IS YOUR VISION PRESCRIPTION FOR (CHOOSE ALL THAT APPLY)?

Seeing far (nearsightedness)

Seeing close (farsightedness)

Double vision (astigmatism)

Bifocals/over-the-counter readers

HAVE YOU HAD AN EYE INJURY OR EYE SURGERY?

yes

no

WHAT IS MOST IMPORTANT TO YOU TO HAVE (SELECT ALL THAT APPLY)?

Good distance vision

Good intermediate vision

Good close up vision

All of the above

IF YOU HAVE CATARACT SURGERY, HOW IMPORTANT IS IT TO YOU TO BE FREE OF GLASSES AND CONTACTS?

Very important

Not important

Not sure

PLEASE PROVIDE YOUR INFORMATION WHERE WE WILL DELIVER YOUR RESULTS.

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