Intake Survey Please take a few moments to answer these questions: Name* First Last Do you ever experience any of the following eye symptoms?: (please check all that apply) Dry Tired Eye Strain Itchy Gritty Watery Burn Floaters Flashes of Light Are your eyes sensitive to bright light and/or night time glare?YesNoHave you or anyone in your family been diagnosed with Macular Degeneration?YesNoAre you concerned about your vision getting worse? Or your child's vision getting worse?YesNoI am concerned about my vision getting worse.I am concerned about my child's vision getting worse.Are you concerned about droopy eyelids?YesNoWe now have a new product that gives an "eye lift" Learn more about UpneeqAre you interested in updating your glasses today?YesNoAre you interested in updating your prescription for contact lenses?YesNoDo you have dizziness and/or light headedness?YesNoDo you experience dizziness and/or light headedness when bending down and standing back up?YesNoDo you feel nauseous while riding in the car?YesNoDo you have difficulty reading while riding in the car?YesNoDo you ever find yourself with your head tilted to one side?YesNoDo you cover or close one eye with near tasks?YesNoDo you skip lines or lose your place while reading?YesNoDo you have headaches and/or facial pain?YesNo
Open Saturdays by appointment only (2 Saturdays per month 9-1)