Eye Health Food Recommendation Form
Help us understand your eye health and dietary habits to provide personalized food recommendations.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Do you currently have any diagnosed eye conditions?
*
No known eye conditions
Dry eyes
Cataracts
Glaucoma
Macular degeneration
Other
How would you rate your current vision?
*
1
2
3
4
5
How often do you consume foods rich in vitamins A, C, and E (e.g., carrots, spinach, citrus fruits, nuts)?
*
Daily
Several times a week
Rarely
Never
Do you have any food allergies or dietary restrictions?
*
No allergies or restrictions
Vegetarian
Vegan
Gluten-free
Nut allergy
Lactose intolerance
Other
Please list any medications or supplements you regularly take (if any):
On average, how many hours per day do you spend looking at screens (computer, phone, TV)?
*
Less than 2 hours
2-4 hours
5-8 hours
More than 8 hours
How often do you wear sunglasses or protect your eyes from sunlight?
*
Always
Sometimes
Rarely
Never
Do you smoke or use tobacco products?
*
No
Yes, occasionally
Yes, regularly
Former user
What are your main goals for improving your eye health? (Select all that apply)
*
Prevent eye strain
Improve night vision
Reduce dryness
Support long-term eye health
Other
Please share any additional information or preferences that may help us tailor your food recommendations:
Get My Recommendations
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