P: (303) 772-3300 | F: (303) 682-3380 | M-F 7:30am – 5:30pm

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BOULDER

3000 Center Green Drive
Suite 250
Boulder, CO 80301

Phone: (303) 772-3300
Fax: (303) 682-3380

LAFAYETTE

300 Exempla Circle
Suite 120
Lafayette, CO 80026
(Located within Exempla Community Physicians Pavilion)

Phone: (303) 772-3300
Fax: (303) 682-3380

LONGMONT

1400 Dry Creek Drive
Longmont, CO 80503

Phone: (303) 772-3300
Fax: (303) 682-3380

GREELEY

1616 15th Street
Greeley, CO 80634
(Located within Welch Eye Clinic)

Phone: (303) 772-3300
Fax: (303) 682-3380

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Step 1 of 4

25%

What is your age range?
- Under 18
- 18 - 39
- 40 - 49
- 50+

Without my glasses and contacts...
check all that apply
- I struggle to drive and see things far away‎ (Nearsighted)
- I struggle to read and see things up close (Farsighted)
- I have distorted vision and cannot see very well‎ (Astigmatism)

What do you usually wear to see?
check all that apply
- Glasses
- Contacts
- Reading Glasses
- Nothing

Do you have any of the following?
check all that apply
- Rheumatoid Arthritis‎
- Multiple Sclerosis‎
- Lupus‎
- Cataracts‎
- Keratoconus‎
- Diabetic Retinopathy‎
- Prior Eye Surgery‎
- Prior serious eye injury‎
- Are you pregnant or nursing?‎
- None of the above‎

Step 1 of 2

50%

Are you experiencing?
- Clouded, blurred, or dim vision?
- Difficulty seeing distant objects?
- Sensitivity to light or glare?
- Difficulty seeing distant objects?
- Seeing a halo around lights?
- Fading or yellowing of colors?
Has your prescription for eyeglasses changed more often than usual?
- Yes
- No
Do you need brighter light for reading?
- Yes
- No
Does your vision sometimes seem distorted?
- Yes
- No
Have you experienced double vision in one eye only?
- Yes
- No
Do you see “ghost” images?
- Yes
- No
How do you prefer to have a member of our clinic’s staff follow up and contact you?
- Phone
- Email

Name*
First Last
Phone*
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