CONTACT LENS QUESTIONNAIRE

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

Patient :

Age :

Occupation :

Do you presently wear contact lenses? Yes
No

What type?
Gas permeable
Daily wear
Soft
Extended wear
Disposable
How often do you replace them?

How old are your current contacts?

Which Doctor examined you most recently for contact lenses?

How many hours a day, on average, do you wear contact lenses?

How many days a week?

When did you begin wearing contact lenses?

If you sleep with your lenses, how often do you remove them?

What contact lens solutions do you use?
Cleaner
Disinfectant/Soaking

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

How often do you enzyme?

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

If yes, for how long?

What type of lenses?

Why did you stop wearing them?

Have you had any infections related to CL wear? Yes
No

Do you have any systemic allergies or asthma? Yes
No

Please check if you have any of the following conditions or symptoms. (CL = contact lenses) Dry eyes
Crusting on eyelids
Discomfort wearing CL’s
Red eyes with CL’s
Short CL wearing time
Frequent CL deposits
Allergies to CL solutions
Glare

Poor vision with CL’s at distance?
at near?

Do you work in a dusty environment, or around chemical fumes? Yes
No

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

Are you interested in wearing colored contact lenses, or special effects contact lenses?

I understand there is an additional fee for a contact lens evaluation & services

Signature

Date

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CONTACT LENS QUESTIONNAIRE