Patient Lifestyle Questionnaire

Patient Lifestyle Questionnaires

Welcome to See Vision Eye Institute! In order to assist you in making the best possible decisions about your vision, we would like to know more about you. Please take a moment to complete this brief questionnaire, designed to help us recommend the options that are the best fit for you and your lifestyle.

How would you most like to use your vision without glasses?*

Computer Work

Outdoor Activities

Driving

Reading and Close Work

Watching TV

Other

Do you wear contact lenses regularly?*

Yes

If you wear contact lenses, are you accustomed to monovision?

Yes

Do you have difficulty seeing in any of the following conditions?*

Car Headlights

Night Driving

Sunshine

Computer

Captions on TV

Small Print / Reading

Other

Do you drive at night?*

Yes

If you drive at night, when?

Professionally

Nightly

Occasionally

How many hours do you spend on your computer or mobile devices per day?*

Where do you like to hold your reading material?*

Close (12 inches)

Intermediate (18 inches)

In your lap

Do you have issues with dry, itchy, irritated, or watery eyes?*

Yes

How often do you have issues with dry, itchy, irritated, or watery eyes?

Occasionally

When Reading or Watching TV

When Outdoors

Frequently

Other

When you experience dry eye symptoms, do you use artificial tears?

Yes

Do you have any additional concerns about your vision that you would like to share with us?* This field is required.

First Name* This field is required.

Last Name* This field is required.

Phone* This field is required.

Email* This field is required.

Privacy Note: By submitting this form, you agree to See Vision Eye Institute's privacy policy and consent to be contacted regarding your cataract screening results and for other related purposes. This field is required.

This field is required.

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Patient Lifestyle Questionnaire

Patient Lifestyle Questionnaires

See Vision Eye Institute Your Life in Focus