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001|What is the purpose of your visit?
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002|If other, please specify:
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003|When was your last eye exam?
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004|Was your last exam at Warby Parker?
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005|Are you pregnant?
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006|Do you smoke?
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007|Do you wear contact lenses?
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008|What brand of contacts do you currently wear?
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009|Are you interested in renewing your contact lens prescription?
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Have you ever been diagnosed with any of the following?
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010|None
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011|Blindness/Loss of Vision
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012|Cancer
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013|Cataracts
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014|Corneal Abrasion
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015|Diabetes
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016|Dry Eye
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017|Eye Infection
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018|Eye Injury
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019|Eye Surgery
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020|Eye Turn/Lazy Eye/amblyopia
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021|Glaucoma
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022|Head Injury
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023|Heart Disease
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024|High Blood Pressure
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025|High Cholesterol
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026|Iritis/Uveitis
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027|Macular Degeneration
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028|Respiratory Illness
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029|Retinal Detachment
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030|Thyroid Disease
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031|Other Eye Diseases
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Has anyone in your FAMILY been diagnosed with any of the following?
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032|None
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033|Blindness/Loss of Vision
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034|Cataracts
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035|Cancer
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036|Diabetes
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037|Dry Eye
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038|Eye Surgery
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039|Eye Turn/Lazy Eye/Amblyopia
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040|Glaucoma
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041|Heart Disease
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042|High Blood Pressure
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043|High Cholesterol
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044|Iritis/Uveitis
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045|Macular Degeneration
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046|Respiratory Illness
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047|Retinal Detachment/Hole/Tear
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048|Thyroid Disease
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049|Other Eye Diseases
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Medications & Allergies
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050|Are you currently taking any medications?
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051|Please list your current medications
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052|Do you have any allergies?
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053|Please list your allergies
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Are you or a member of your household currently (or in the last 14 days) experiencing any of the following symptoms?
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054|Fever or chills
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055|Cough
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056|Shortness of breath or difficulty breathing
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057|Fatigue
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058|Muscle or body aches
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059|Headache
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060|New loss of taste or smell
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061|Sore throat
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062|Congestion or runny nose
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063|Nausea or vomiting
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064|Diarrhea
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065|None of the above
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066|Have you been exposed to someone who has either tested positive for COVID-19 or had symptoms within the last 14 days
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067|If your doctor issues you a prescription, do you consent to receive that prescription digitally via email?
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