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Contact Lens Questionnaire Print, fill out, and bring to your appointment if you wish to speed things up. Name:______________________________________Date:____/____/____ When were you originally fit with contact lenses?___________________________ By whom? _______________________ Address:___________________________ What type? Hard Firm Gas Permeable Soft Daily Astigmatic Extended Disposable Were you ever refit with contact lenses?…Yes/No If yes, When _____________ By whom? _______________________ Address:__________________________ What type? Hard Firm Gas Permeable Soft Daily Astigmatic Extended Disposable
Do you use eye drops? If so, what type? Yes/No _______________ What is your average wearing time? _____________ Your maximum wearing time? _____________ Are you without spare glasses for backup or part time wear? ..........Yes/No If you have glasses, is your vision unacceptable with them? .............Yes/No How long does it take for your vision to clear with your glasses, after you have removed your contact lenses?______ What types of solutions do you use on your contacts? Cleaning: Soaking/disinfecting: Saline (aerosol - non aerosol): Hand soap Enzyming: _____________________________ Rewetting: ____________________________ Artificial tears: ________________________ Hand creams __________________________ Have you ever overworn or slept with your contact lenses on? ............................Yes/No How long have you lived in Colorado? ________ List your allergies: ___________________________________________________ Are you taking any medications? ............................................Yes/No If so, what? Do you use or have you used oral contraceptives? .........................................Yes/No Do you have only one pair of contact lenses? .............................................Yes/No Do you want to update to a more advanced type of contact lens? .......................Yes/No Do you want/need non prescription sun glasses? ...........................................Yes/No How many times have your present contact lenses been polished? ____ When last?.__________ When was the last time you wore your contact lenses? _____________ How old are your current contact lenses? _____________ When was your last complete eye examination? _____________ When was your last contact lens evaluation? _____________ |