Name*

First Last

Do you ever experience any of the following eye symptoms?: (please check all that apply)

Are your eyes sensitive to bright light and/or night time glare?

Have you or anyone in your family been diagnosed with Macular Degeneration?

Are you concerned about your vision getting worse? Or your child's vision getting worse?

Are you concerned about droopy eyelids?

Are you interested in updating your glasses today?

Are you interested in updating your prescription for contact lenses?

Do you have dizziness and/or light headedness?

Do you experience dizziness and/or light headedness when bending down and standing back up?

Do you feel nauseous while riding in the car?

Do you have difficulty reading while riding in the car?

Do you ever find yourself with your head tilted to one side?

Do you cover or close one eye with near tasks?

Do you skip lines or lose your place while reading?

Do you have headaches and/or facial pain?

Intake Survey

Heights Eye Center