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? Yes No Have you or anyone in your family been diagnosed with Macular Degeneration? Yes No Are you concerned about your vision getting worse? Or your child's vision getting worse? Yes No I am concerned about my vision getting worse. I am concerned about my child's vision getting worse. Are you concerned about droopy eyelids? Yes No We now have a new product that gives an "eye lift" Learn more about UpneeqAre you interested in updating your glasses today? Yes No Are you interested in updating your prescription for contact lenses? Yes No Do you have dizziness and/or light headedness? Yes No Do you experience dizziness and/or light headedness when bending down and standing back up? Yes No Do you feel nauseous while riding in the car? Yes No Do you have difficulty reading while riding in the car? Yes No Do you ever find yourself with your head tilted to one side? Yes No Do you cover or close one eye with near tasks? Yes No Do you skip lines or lose your place while reading? Yes No Do you have headaches and/or facial pain? Yes No
Open Saturdays by appointment only (2 Saturdays per month 9-1)