NearVision CK® Self-Evaluation TEST

1. Are you having reading vision problems?
   Yes
   No
2. Are you age 40 or older?
   Yes
   No
3. Are you pregnant or do you suffer from any chronic illness or disease?
   Yes
   No
4. What was your vision like before 40?
   Very Good, glasses not required
   Not Good, had distance vision issues
   None of the above
5. Reading a menu is
   Possible without reading glasses
   Possible without reading glasses
6. Have you ever had monovision with either lasik or contact lenses?
   Yes
   No
7. Have you previously had lasik eye surgery?
   Yes
   No
8. Best Contact Time*:

   M-F 9am - 1pm M-F 1pm - 5pm M-F 5pm - 9pm Sat 10am - 1pm Sat 10am - 1pm Sun 1pm - 7pm Sun 1pm - 7pm