Monovision Contact Lens Evaluation Form
Use this form to collect information needed to evaluate monovision contact lens suitability and fitting needs.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Vision and Contact Lens History
Do you currently wear contact lenses?
*
Yes
No
Current correction type
*
Glasses
Soft contacts
Rigid gas permeable contacts
Other
Have you tried monovision before?
*
Yes
No
Prior contact lens or vision correction notes
Eye Health and Symptoms
Current eye symptoms or concerns
*
Dryness
Irritation
Redness
Blurred vision
Headaches
Difficulty reading
Difficulty with distance vision
None of these
Other
Additional notes or clarification
Known eye conditions or relevant history
Lifestyle and Monovision Goals
Daily visual needs and activities
*
Computer work
Reading
Driving
Night driving
Outdoor activities
Sports
Other
Main goals or concerns for monovision fitting
*
Willingness to adapt to different vision strengths in each eye
*
Yes
Maybe
No
Evaluation Details
Preferred Evaluation Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Special Instructions for the Evaluator
Information Provided is Accurate and Complete
*
Yes
No
Submit
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