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Review of Systems
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Please indicate if you have an active issue with the below listed body systems.
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For those that DO have active issues, please select from the list.
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General
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General
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Skin
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Skin
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Head, Ears, Nose, and Throat
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HEENT
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Cardiovascular
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Cardiovascular
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Respiratory
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Respiratory
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GI
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GI
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Musculoskeletal
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MSK
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Urinary
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Urinary
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Endocrine
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Endocrine
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Neurological
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Neurological
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Psychiatric
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Psychiatric
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How did you hear about us?
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Feel free to give more details.
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Visual Lifestyle Questionnaire
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Enough with the boring questions. Let’s talk about your goals!
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What is your occupation? If retired, please type retired and then your former occupation.
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Currently, what do you use primarily for the following distances?
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Distance Vision (driving, golf, tennis, other sports, watching TV)
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Mid-range Vision. (computer, menus, price tags, cooking, board games)
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Near Vision (reading books, smartphones, tablets, e-readers, sewing, detailed handwork)
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Select if you do "Monovision" with contact lenses.
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For which eye is distance clear?
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Do you like your monovision?
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At what visual distance do you spend the MOST time looking?
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Which visual distance would you prefer to see without glasses?
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What are activities, sports or hobbies that you frequently do? Please put an "x" after the ones that are affected by your vision
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Please check the single statement that best describes you in terms of night vision:
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If you had to wear glasses after surgery for one distance, for which distance would you be most willing?
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Where do you prefer to hold your reading material?
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If you had good Distance/Near vision but saw halos/starbursts around lights at night, would you like that option?
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If you had good Distance/Mid-range Vision but needed glasses for near, would you like that option?
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Please select where you personality falls. (1- easy going, 5 - perfectionist)
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Anything special we need to know?
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