Patient Visual Needs Assessment

Drs. Quinn, Quinn and Crawford

 

Your Name__________________________††† Age____†††††††† Todayís Date___________

 

1.So we may best meet your visual needs, please list specific visual demands you have (work or recreation related): ________________________________________________________________________

2.What is your primary form of visual correction?(please circle)††

††††††††††† glasses††††† soft contact lenses††††††† gas permeable contact lenses†††††† no correction††

 

 

3.†† How do you wear your current glasses?(please circle)††

††††††††††† all day††††††††††† distance tasks†††††††††††† near tasks††††††††† as needed††††††† donít wear

 

4.Are you interested in considering contact lenses? (please circle one)

* To wear daily* To wear on occasion* NEW:To wear continuously for up to 1month

††† * Haven't considered†††††† * I already wear†††††† * Not interested

 

5.Are you interested in contact lenses that will change or enhance eye color?††† YN

 

6. Have you worn contact lenses in the past? (please circle)

††††††††††† Soft lenses††††††† Gas permeable lenses††††††† Hard lenses†††† Haven't worn

 

7. Are you interested in considering Corneal Refractive Therapy (wearing an oxygen permeable device overnight to gently re-shape the eye, so when removed in the morning, uncorrected vision is clear)? †† Yes†††† No††††††††††† Not sure

 

8. Are you interested in considering laser treatment to reduce your dependence on

††††† corrective lenses?†††† Yes†††† No†††††† Not sure

 

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Thank you!Please return this form to the receptionist.