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Low Vision Questionnaire

Please carefully completing our questionnaires. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs.

Please check one of the following:

General Information

Patient History

Vision History

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Review of Systems

Do you currently, or have you ever had any problems in the following areas? If you do, please explain.


Ears, Nose, Mouth, and Throat




Bones, Joints, and Muscles

Family History

If anyone has any of the following conditions, please indicate who. If not applicable, please leave it blank.

Low Vision Supplement