Patient Trial Lens Feedback

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* 1. Your Name

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* 2. Your Optometrist

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* 3. Current Lens Type

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* 4. I am testing the lens in

One eye

Both Eyes

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* 5. I am completing this survey after ____ days of wearing the lens.

Thinking about your regular contact lenses, please rate them below on the following qualities.

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* 6. Preparing the lenses for insertion

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. Insertion of the lenses

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Removal of the lenses

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. Initial comfort

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 10. Level of comfort throughout the day

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. End of day comfort

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 12. Visual clarity

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

Thinking about the new lens that you are trying out, please rate it below on the following qualities.

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* 13. General handling

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 14. Preparing the lenses for insertion

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 15. Insertion of the lenses

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 16. Removal of the lenses

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 17. General comfort

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 18. Initial comfort

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 19. Level of comfort throughout the day

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 20. End of day comfort

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 21. General vision

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 22. Visual quality

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 23. Visual clarity

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 24. Sight during daily activities

The Worst

Neutral

The Best

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 25. Please share any other thoughts or feedback about the lens.

We appreciate your response. Thank you!