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Vision Screening Questionnaire - Free Healthcare Template | ZenBuild | ZenBuild

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Vision Screening Questionnaire

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.

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Vision Screening Questionnaire

Please complete this questionnaire about your vision and eye health before your appointment.

Patient Name*

Date of Last Eye Exam

Current Vision Correction*

Current Vision Symptoms (select all that apply)

Blurry vision (distance)Blurry vision (near / reading)Double visionEye pain or discomfortFrequent headachesDry or irritated eyesFloaters or flashes of lightSensitivity to light

Family History of Eye Conditions (select all that apply)

GlaucomaMacular degenerationCataractsRetinal detachmentNone known

Average Daily Screen Time (hours)

Do you experience eye strain from computer or phone use?*

Yes, frequentlyOccasionallyRarely or never

Additional Eye Health Concerns

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

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healthcarevisionoptometryscreening