Questionnaires
Visits to our office can be made more efficient and productive for you by completing questionnaires and history forms before the visit. After completion of the forms you can either email / fax / regular mail or bring them with you for the appointment. Receiving the form before the exam will allow us to prepare for your visit and speed you along.
Please download the forms that are most appropriate for your situation. All forms require that you have the free Adobe Reader.
Agape Learning Center:
- School Children Questionnaire for Learning Problem Assessments
- Reversals Questionnaire (complete if student reverses letters, numbers or words)
- Screening Questionnaire (Not sure if we can help? Check this out!)
Agape Optometry Center:
- Vision Service Plan (VSP) Patient History Questionnaire (required completion by VSP)
-
Vision Service
Plan (VSP) Patient Consent Form (required completion by VSP).
- Non-Vision Service Plan
(non-VSP)
Medical Questionnaire.
- Acquired Brain Injury Questionnaire (complete if appropriate)
- Allergy Eye Questionnaire (complete if your eyes are itchy and red)
- Computer User Questionnaire (complete if you work on a computer)
- Dry Eye Questionnaire (complete if appropriate)
- Ocular Surface Disease Questionnaire (complete if appropriate)
-
Refractive
Surgery (LASIK) Questionnaire (complete if you are interested in Laser
Vision)
If you wear glasses or contact lenses, we suggest viewing the following to make your visit more efficient:
Light and Fashionable Frames
Lens Types, Materials, Protective Coatings, Light Control
Corneal Molding or Accelerated Orthokeratology
Refractive Surgery or Laser Vision
100 North Rancho Road, Suite #1
Thousand Oaks, CA 91362
Phone (805)495-3937 Fax (805)373-9843
E-Mail