LIFESTYLE QUESTIONNAIRE
SusqEye
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Eye related to complaints with your glasses on:
*
Right Eye
Left Eye
1. Would you like to reduce or eliminate the need for glasses?
Yes
No
2. Do you have glare or halos around lights?
*
Yes
No
3. Do you have double or distorted vision?
*
Yes
No
4. Do you have difficulty with color vision?
*
Yes
No
5. Do you have difficulty with depth perception or in going up or down stairs?
Yes
No
6. Do you have difficulty seeing at a distance?
*
Yes
No
7. Do bright lights cause a decrease in vision?
*
Yes
No
8. Does glare make driving difficult at night or have you stopped driving?
*
Yes
No
9. Do you have difficulty seeing TV or movies?
*
Yes
No
10. Do you have difficulty reading small print?
*
Yes
No
11. Do you have difficulty performing handiwork?
*
Yes
No
12. Do you have difficulty with leisure activities?
*
Yes
No
13. Do you have difficulty performing routine activities at home?
*
Yes
No
What are your hobbies or interests?
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*
SUBMIT FORM
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