Ophthalmology — Sun City, Sun City West, Surprise & Anthem
Take a moment to analyze your clarity and focus...

Accurate vision gives you the ability to see life with precision. It offers a sense of assurance while driving at night, and allows us to comfortably perceive our surroundings. The following questions are intended for you to honestly assess your eyesight and to help you better understand vision improvements that could enhance your quality of life. Think about your vision and ask yourself the following questions:

Are objects constantly blurred and out of focus? Yes     No
Are you a diabetic? Yes     No
Are you a diabetic with fluctuations in vision quality? Yes     No
Do you have eye pain? Yes     No
Are your eyes red and have a scratchy feeling? Yes     No
Do have trouble focusing on distant objects? Yes     No
Do you ever experience double vision? Yes     No
Do you experience a burning sensation upon closing your eyes? Yes     No
Do you experience difficulty seeing at night? Yes     No
Do you feel discomfort in your eye, almost like you have sand in it? Yes     No
Do you find yourself squinting to focus? Yes     No
Do you get headaches or strain your eyes when reading? Yes     No
Do you have a difficult time distinguishing between different colors? Yes     No
Do you have an increased sensitivity to light? Yes     No
Do you have difficulty seeing in low light situations? Yes     No
Do you have red, itchy, puffy eyes? Yes     No
Do you see partial double images around an object when trying to focus? Yes     No
Have you experienced an increase in drainage fluid that crusts around your eyes? Yes     No
Have you experienced an increased feeling of pressure behind one or both eyes? Yes     No
Have you experienced pain in your eye after an injury? Yes     No


If you answered yes to ANY of these questions, it may be caused by a serious eye condition. To receive a personalized assessment of your ocular health analysis, please complete this form.

Recognizing a change in vision or unfamiliar pain is the first step in determining chronic eye conditions. Contact our office today to schedule a comprehensive eye exam.

  Please enter the text exactly as it appears:

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

Home  |  Dr. Schaffer  |  About Us  |  Services  |  FAQ  |  Appointments  |  Patient Forms  |  Contact Us
© 2018 Charles L. Schaffer, MD - All Rights Reserved  •  Site by Porch Puppy Online