Contact Lens Questionnaire

This questionnaire is designed to help us better evaluate your contact lens needs. Please answer as completely as possible. Thank you for your time.

Date:

Patient Name:

Age:

Occupation:

Telephone:

Address:

City:

State:

1. Do you currently wear contact lenses? : Yes
No (if, no skip to #11)

2. Type of Lens? :Gas permeable
Soft
Disposable

Type of wear? : Daily wear
Extended wear

3. How often do you replace them? :

4. How old are your current contacts? :

5. Which Doctor examined you most recently for contact lenses? :

6. How many hours a day, on average, do you wear contacts? :

7. How many days a week? :

8. How many years ago did you begin wearing contact lenses? :

9. If you sleep with your lenses on, how often do you remove them? :

10. What brand of contact lens solutions do you use? :

Do you clean after each wear in : the evening, or in
the morning?

How often do you enzyme? :

11. If you are not currently wearing contact lenses, have you ever worn, or tried to wear contacts in the past? : Yes
No

If yes, how long? :

What type of lenses? :

12. Why did you stop wearing them? :

13. Have you had any eye infections related to contact lens wear? : Yes
No

14. Do you have any systemic allergies or asthma? : Yes
No

15. Do you work in a dusty environment or around chemical fumes? : Yes
No

16. How would you describe your desire to wear contact lenses? : Mild
Moderate
Strong

Please check if you have any of the following conditions or symptoms from wearing contact lenses. (CL=Contact lenses) : Dry eyes
Crusting on eyelids
Discomfort
Red eyes
Short wearing time
Frequent CL deposits
Allergies to solutions
Poor distance vision
Poor near vision

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Contact Lens Questionnaire

This questionnaire is designed to help us better evaluate your contact lens needs. Please answer as completely as possible. Thank you for your time.