Address
Patient Ocular History
List any vision complaints you are having:
blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
When was your last eye exam?
My last eye examination was 1 year ago.
My last eye examination was 2 years ago
My last eye examination was 3 years ago
My last eye examination was over 3 years ago
Check the box for any conditions that apply:
Do you currently wear eyeglasses? If "YES", How long have you had the current prescription?
NO, I do not wear eyeglasses
I do not know how old my prescription is
My eyeglasses are 1 year old
My eyeglasses are 2 years old
My eyeglasses are over 3 years old
Contact Lens Wearers Only
Do you currently wear contact lenses? If "YES" , how long have you worn them?
I have been wearing contacts for 1-5 years
I have been wearing contacts over 5 years
How many hours a day do you wear your contact lenses?
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 Hours
9 Hours
10 Hours
12 Hours
14 Hours
15+ hours
Overnight
1 week
2 weeks
1 month
How frequently do you replace your contact lenses ? (every 2 weeks, month, year, etc.)
2 weeks
monthly
daily
weekly
quarterly
yearly
When irritated
When torn
Never
What contact lens solutions do you use?
Any brand
Aquify
BioTrue
Boston
ClearCare
Complete
Costco/Kirkland
Generic
None
Optifree
Optifree Express
Optifree Pure Moist
Optimum Extra
Pure Moist
Renu
Revitalens
Unknown
Lobob
Medical History
Check the box for any conditions that apply: