Adult Vision Risk Assessment Please enter your contact information First Name Last Name Phone Email Birthdate GenderPlease select... Male Female Other EthnicityPlease select... African American or Black Asian Caucasian Hispanic/Latino Mexican American/Chicano Multi-Ethnic Native American or Alaska American Native Hawaiian or Pacific Islander Southeast Asian Other Specify Ethnicity for Southeast Asian or Other Pre-Screening Form On a scale of 1 to 3, 1 being not comfortable at all and 3 being very comfortable, would you feel comfortable making an eye exam appointment for yourself?Please select... 1 2 3 Do you think children’s vision impacts learning? Please select... Yes No Are you concerned about screen time/digital devices and children’s vision? Please select... Yes No Risk Assessment I acknowledge this risk assessment form isn't an eye exam.* What year was your last eye exam? If unknown, leave blank. Risk Assessment Questions Do you have blood relatives with glaucoma?Please select... Yes No Unsure Has a doctor treated you for or said you have glaucoma?Please select... Yes No Unsure Have you ever had an eye injury or eye surgery?Please select... Yes No Unsure Have you noticed a change in vision in the last 12 months?Please select... Yes No Unsure Do you have constant pain in or around your eyes?Please select... Yes No Unsure Are you black, Hispanic or Latino, and age 40 and older?Please select... Yes No Are you age 60 or older?Please select... Yes No Was your last dilated eye exam more than two years ago?Please select... Yes No Unsure Do you have diabetes?Please select... Yes No If you do have diabetes, was your last dilated eye exam more than one year ago?Please select... Yes No Unsure Questions? Would you like to sign up for our monthly FY-Eye Newsletter? Next Steps: Do You Need Vision Care Do you need translation services?Please select... Yes No Do you have vision health insurance?Please select... Yes No Unsure Can you afford vision care if you do not have coverage?Please select... Yes No Do you need resources for an eye doctor?Please select... Yes No Contact Information
