Plaza Lane Optometry

Computer Vision Form

General Information

Legal Name:  

Birth Date: 

General Visual Information

Time spent at computer?  hours per day.

Work is performed while Sitting Other (please describe)

If other, describe:

Are you experiencing any of the following symptoms while on your computer?

 Headaches Blurred Near Vision Blurred Distance Vision Burning, Itching, or Read Eyes Slowness in Focusing (Distabt to near and back) Double Vision Sore or Tired Eyes (Strain) Back Pain Glare (Light) Sensitivity Dry or Watery Eyes Neck and Shoulder Pain

Do you wear glasses while working on the computer?
 Yes No

Do you wear contact lenses while working at the computer?
 Yes No

Do you view reference materials while working at the computer?
 Yes No

If yes, what percentage of the time? 

Distances / Direction

Viewing distance (eye to computer screen) is  inches

Viewing distance (eye to computer keyboard) is  inches

Viewing distance (eye to reference material) is  inches

The center of the computer screen is  Above Equal to Below eye level

If above or below, by how many inches? 

Reference material is  Above Equal to Below eye level

If above or below, by how many inches? 

Digital Signature

By typing my name in the text box below, I am validating that all of the above information is accurate and up-to-date.

Digital Signature