Accommodation and Convergence Eye Test Questionnaire Form
Please complete the Accommodation and Convergence Eye Test Questionnaire Form to help us prepare your upcoming eye test. All questions are designed to ensure the most accurate and comfortable assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently wear corrective lenses (glasses or contact lenses)?
*
Glasses
Contact Lenses
Both
Neither
What is the main reason for your eye test today?
*
Please Select
Routine check-up
Experiencing vision difficulties
Follow-up for previous condition
Referred by another provider
Other
Have you experienced any of the following recently? (Select all that apply)
*
Double vision
Eye strain
Headaches
Blurred vision
Difficulty focusing
None of the above
How often do you experience symptoms related to eye strain or discomfort?
*
Never
Occasionally
Frequently
Constantly
Have you had an eye exam in the past two years?
*
Yes
No
Do you have a history of any eye conditions or surgeries?
*
Yes
No
If yes, please describe your eye condition(s) or surgery (if applicable)
Is there anything else you would like us to know before your eye test?
Submit Questionnaire
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