562.421.2020

HOURS:
Monday, Tuesday & Friday: 8:00 - 5:00 (Closed during lunch 12pm-1:30pm)
Wednesday: 8:00am - 12:30pm
Thursday: 8:00am - 5:30pm (Closed during lunch 12pm-1:30pm)
Saturday & Sunday: Closed

5512 E. Britton Drive, Suite 200. Long Beach, CA 90815
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Patient Questionnaire


Patient Name        Date   

Email Address   

PERSONAL EYE HISTORY:

Have you had any eye operations?     yes     no

Type     Date     

Have you had an eye injury?     yes     no

Type     Date     

Please check any eye conditions you currently have:

Glaucoma   
Cataracts
Blurred Vision
Macular Degeneration
Dry Eyes
Eyestrain
Other  

Vision needs:

Extended Reading
Very close/fine detail
Driving
Computer - Hours per day   
Glare Control
Sun Protection
Sports

If you are having any problems with your vision, please check which distance(s) bother you:

Far away, distance
Close up, reading
In Between, computer, card games

What hobbies do you enjoy?

Do you engage in activities that could cause eye injury?    yes    no

Do you have problems with bright lights or glare?    yes     no

Do you currently wear glasses?    yes    no

Do you feel glasses get in the way of any activities?    yes    no    (golf, swimming, running etc.)

Do you wear contacts lenses?    yes    no

If you wear contact lenses, are you satisfied with your:

Vision     yes    no

Comfort     yes    no

Any Dryness     yes    no

What type of contact lenses do you wear?

What method of solution do you use to clean/disinfect your lenses?

How often do you replace your contact lenses?

Do you ever sleep in your contact lenses?    yes    no

If yes, how often?

Would you like to discuss the latest advances in contact lenses and your options for vision correction?
yes    no

PRODUCTS OR SERVICES OF INTEREST TO YOU (please check all that apply)

Glasses: Distance/Reading
Contact Lenses
Computer glasses
Sunglasses/polarized
Anti-glare coatings
Protective Sports Eyewear
Itchy Eye Relief
Drooping eyelids
Dry Eye Relief
Fresh-Kote®
Facial wrinkles/lines
Facial folds
Grow eyelashes longer thinker & darker Latisse®
BOTOX® Cosmetic
Elastiderm® Eye Cream
Elastilash® lash enhancer
Juvéderm®

Are you interested in speaking with one of our professional staff regarding our cosmetic products and how they can help you achieve your desires?    yes    no