Eye Prescription Self-Assessment Questionnaire
Evaluate your visual comfort and habits to help identify if you may benefit from an updated eye prescription.
How clear is your vision when reading text up close (e.g., books, phones, labels)?
*
Very blurry
1
2
3
4
Very clear
5
1 is Very blurry, 5 is Very clear
How clear is your vision when looking at distant objects (e.g., signs, screens across the room)?
*
Very blurry
1
2
3
4
Very clear
5
1 is Very blurry, 5 is Very clear
Do you experience frequent eye strain or tired eyes?
*
Never
Rarely
Sometimes
Often
Always
How often do you get headaches after reading or screen time?
*
Never
Rarely
Sometimes
Often
Always
Do you currently wear prescription glasses or contact lenses?
*
No
Yes, glasses
Yes, contact lenses
Yes, both
How comfortable are you with your current eyewear (if any)?
*
Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
How many hours per day do you spend using digital screens (computer, phone, tablet)?
*
Please Select
Less than 2 hours
2-4 hours
4-6 hours
6-8 hours
More than 8 hours
Do you find yourself squinting to see clearly at any distance?
*
Never
Rarely
Sometimes
Often
Always
Have you noticed any recent changes in your vision?
*
No change
Slight change
Moderate change
Significant change
How soon do you plan to schedule your next comprehensive eye exam?
*
Please Select
Within 1 month
1-3 months
3-6 months
6-12 months
No plans yet
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