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* Date Format: MM slash DD slash YYYY Do you currently wear glasses or contacts?YesNoHow often?All the timeSometimesRarelyFor what purpose?Far DistanceNear/ReadingIntermediate/ComputerIf you wear contacts, are they?Soft LensesGas Permeable (Hard) LensesCheck 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?YesNoAre you pregnant or planning to become pregnant within the next year?YesNoList any additional occupational, recreational or other activities you currently engage in.How did you learn about us?Office Location?*DoverSeafordMillvilleCAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Copyright © [year] Eye Specialists of Delaware. All Rights Reserved.
