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:

Address:

City:

State & Zip:

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