Questionnaire - eyeness

Gender

Name

First Name

Date of Birth

Occupation

Adress

ZIP/City

private phone

business phone

Mobile

E-mail

Ophthalmologist

Recommendation/Referral

Do you play sports?

Yes No

Last visit to your ophthalmologist

Reason for visit

Have you already worn contact lenses?

Yes No

Do you wear spectacles?

Yes No

How would you like to wear your contact lenses?

sporadically daily up to 16h 24h non stop only at night

Do you feel healthy at the moment?

Yes No

Have you been recently or are you currently under medical treatment?

Yes No

Do you regularly take medication, hormone or vitamin preparations?

Yes No

Are you prone to allergies?

Yes No

Do you smoke?

Yes No Rarely

Have you ever suffered an eye injury or illness?

Yes No

What's your blood pressure?

For women: Are you currently pregnant?

Yes No