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*

Date*

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:*

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

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Email

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Vision & Lifestyle Questionnaire