Vision Lifestyle Questionnaire

If you prefer, you can print a hard copy of this form and fax it to 561-981-8460..

There are a variety of options for refractive surgery that will not only give you clearer vision but may also reduce your dependency on glasses. Please help us better understand what is important to you in order to determine which option is best suited for your lifestyle. Please circle the following activities that you do on a regular basis and are important to your lifestyle:

On a scale from 1 to 10, please move the slider where it best describes how you feel about the following.
1 = I want to wear glasses | 10 = I don’t want to wear glasses

0
0
0
Sign Here