Form #3: Today’s Visit Thank you for answering these questions about your eyes to help us serve you better.Name First Last Do you currently wear glasses? Yes No If yes Full Time Reading/Near work Are you planning on getting new glasses today? Yes No Unsure If yes Everyday glasses Computer glasses Reading glasses RX Sunglasses TV glasses Driving glasses RX Sports glasses RX Safety glasses Do you wear contact lenses? Yes No Are you renewing your contact lens prescription today? Yes No Unsure Do you have difficulty seeing at night? Yes No Do you wear anything to protect your eyes from the sun? Yes No Do you use a computer/phone/tablet over 4 hours daily? Yes No Do you ever experience:NeverSometimesFrequentlyGritty or sandy sensation?Itchy eyes?Itchy eyelids?Fluctuating vision?Eye pain or soreness? Print this form
