First Name

Last Name

Email Address

Phone Number

Has your vision been getting progressively worse? Has your vision been getting progressively worse? Yes No

Do you see glare of halos around lights? Do you see glare of halos around lights? Yes No

What is your age? What is your age? Under 21 21-50 50+

Do you have difficulty with color vision, or are things looking dingy or yellowish? Do you have difficulty with color vision, or are things looking dingy or yellowish? Yes No

Do you have difficulty with depth perception or with going up and down stairs? Do you have difficulty with depth perception or with going up and down stairs? Yes No

Do bright lights or sunny days cause a decrease in your vision? Do bright lights or sunny days cause a decrease in your vision? Yes No

Are you having difficulty recognizing faces you are familiar with? Are you having difficulty recognizing faces you are familiar with? Yes No

How many times has your prescription changed in the last 5 years? How many times has your prescription changed in the last 5 years? 0 - 1 2 - 3 4 - 5

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