Vision Screening Questionnaire

Vision Screening Questionnaire — Form Fields

This healthcare template includes 8 fields. Vision screening questionnaire for patients to report visual symptoms, eye health history, and current vision concerns. Suitable for optometry offices, ophthalmology clinics, and school health programs. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Last Eye Exam (text, optional)
• Current Vision Correction (dropdown selection, required) — options: Glasses, Contact lenses, Both glasses and contacts, Had LASIK / refractive surgery, None
• Current Vision Symptoms (select all that apply) (checkboxes, optional) — options: Blurry vision (distance), Blurry vision (near / reading), Double vision, Eye pain or discomfort, Frequent headaches, Dry or irritated eyes, Floaters or flashes of light, Sensitivity to light
• Family History of Eye Conditions (select all that apply) (checkboxes, optional) — options: Glaucoma, Macular degeneration, Cataracts, Retinal detachment, None known
• Average Daily Screen Time (hours) (number, optional)
• Do you experience eye strain from computer or phone use? (multiple choice, required) — options: Yes, frequently, Occasionally, Rarely or never
• Additional Eye Health Concerns (long text, optional)