Vision & Lifestyle Questionnaire Please take a few moments to complete the questionnaire. This, along with your dilated preoperative exam, will assist Eye Specialists of Delaware in choosing the best refractive treatment option for you. Name* First Last Date* MM slash DD slash YYYY Do you currently wear glasses or contacts? Yes No How often? All the time Sometimes Rarely For what purpose? Far Distance Near/Reading Intermediate/Computer If you wear contacts, are they? Soft Lenses Gas Permeable (Hard) Lenses Check the following activities you do on a regular basis:* Read newspaper/books Attend concerts/plays/movies Bicycle Use computer Photography Paperwork/writing Shop Use hand-held devices (smart phones, tablets, etc.) Play cards Golf Drive: Daytime and/or Nighttime Spectator at sporting events Read medicine bottles Play musical instrument(s) Sew/needlepoint Water sports Paint/draw Travel Dining at restaurants Play contact sports (football, basketball, boxing, etc) Play tennis Hunt or Fish Cook Bowling What is your occupation? Are you currently enlisted or planning on enlisting in the military or law enforcement? Yes No Are you pregnant or planning to become pregnant within the next year? Yes No List any additional occupational, recreational or other activities you currently engage in.How did you learn about us?Office Location?* Dover Seaford Millville CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Copyright © 2022 Eye Specialists of Delaware. All Rights Reserved.
