[Robert Nguyen] KleinwoodVision.com Myopia Survey

Are you wearing RX glasses?*

YesNo

Since what age have you worn glasses?

Are you wearing RX contact lenses?*

YesNo

Since what age have you worn contacts?

Do you have cataract?*

YesNo

Did you have surgery for cataract?*

YesNo

Do you have glaucoma?*

YesNo

Did you have surgery for glaucoma?*

YesNo

Do you have retinal detachment?*

YesNo

Did you have retinal detachment surgery?*

YesNo

Did you have a severe eye injury?*

YesNo

Did you have surgery for this injury?*

YesNo

Did you have a cornea problem or LASIK?*

YesNo

Did you have cornea surgery or LASIK complications?*

YesNo

Do you have any other eye disorder?*

YesNo

What is the other eye disorder?
Did you have surgery for this disorder?*

YesNo

Is your father short-sighted?*

short-sightednormalunknown

Is your mother short-sighted?*

short-sightednormalunknown

Thank you for providing this information. We'll reach out to schedule your appointment shortly.
Full Name*
Phone Number*
Email*
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