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Are you overdue for your eye exam? (Adults 19-64 should have an exam once every two years. Adults 65 or older should have an exam every year.)

Yes
No

Do you have tired, dry or burning eyes?

Yes
No

Do you rub your eyes frequently?

Yes
No

Do have difficulty seeing at night?

Yes
No

Do you lose track of people and objects not within immediate view?

Yes
No

Do you have difficulty parking your car?

Yes
No

Do you think that interior lighting or outdoor twilight seems insufficient?

Yes
No

Do you notice unusual "spots and floaters" in your field of vision?

Yes
No

Do you notice that objects appear disjointed or crooked?

Yes
No

Do you notice an increased sensitivity to glare?

Yes
No

Do you handle industrial chemicals or machinery without complete eye protection?

Yes
No

Do you play hockey or eye-hazardous racquet sports like tennis or squash?

Yes
No

Do you have trouble judging distances without tilting or moving your head?

Yes
No

Do you react too slowly during play?

Yes
No

Do you have difficulty following your grandchild/child at play on a soccer field?

Yes
No

Do you have difficulty spotting your golf ball in play?

Yes
No

Do you wear contact lenses but haven't had an annual contact lens exam with your B.C. Optometrist?

Yes
No

Do you smoke?

Yes
No

Do you have diabetes?

Yes
No

Do you expose yourself to sunlight through natural or artificial tanning?

Yes
No

Do you go to the beach or ski without proper eyewear?

Yes
No

Do you have an imbalanced diet, or a lack of green, leafy vegetables?

Yes
No

Do you have an imbalanced diet and not take vitamin supplements?

Yes
No

Do you wear facial cosmetics?

Yes
No

Do you have difficulty deciphering fine print?

Yes
No

Do you have trouble switching focus between reading and writing?

Yes
No

Do you experience headaches or eye strain while using a computer or afterward?

Yes
No

Do you avoid close work?

Yes
No

Do you work outdoors for prolonged periods of time?

Yes
No

Have you noticed changes relating to oral contraceptives or the onset of menopause?

Yes
No