Evansville Eyecare Associates pre-visit questionnaire.
Please fill out the appropriate sections.
Patient Name:
Frequent computer user:
How long do you spend at the computer each day?
How far away are you from the computer screen?
Do you wear glasses? If Yes what type?
Do you have vision problems with your glasses at the computer?
Do you wear contacts?
Do you have problems with contact lens comfort at the computer?
Currently wears glasses:
Do you currently wear glasses? Time worn?
Type of glasses? Worn? For?
Glasses Owned? (Check all that apply.)
:Single Vision
:BiFocals
:TriFocals
:Progressive
:Back-Up
:Safety
:Sports
Do you drive?
Do you have visual difficulty when driving?
Do you have glare problems?
Do you have problems with night vision?
Have you had trouble in the past with glasses?
If Yes, what trouble?
Do you wear sunglasses?
Are your sunglasses your current prescription?
Currently wears contact lenses or are interested in wearing contact lenses:
If not a contact lens wearer, are you interested in trying contact lenses at this time?
Have you ever tried to wear contact lenses?
Reason for stopping?
Do you currently wear contact lenses? Time worn?
Type and brand of contact lenses?
Today’s wearing time?
How many hours per day?
Please rate the following on a scale of 1-10, with 1 being POOR and 10 being EXCELLENT
Lens Comfort - Distance Vision - Near Vision
What contact solutions do you use?
Cleaner:
Disinfectant:
Enzyme:
Special vision needs for work, sports, or hobbies:
Computer:
Are you a frequent computer user?
Do you experience visual discomfort while at the computer?
Safety Glasses:
Do you do a lot of yard work, carpentry, or painting?
Occupational:
Do you work with a lot of machinery, or have any specific visual/glasses needs for your job?
Sports/Hobbies:
What activities do you enjoy in your spare time?
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Evansville Eyecare Associates, Inc.

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