T: (845) 986-5367
104 Main Street
Warwick, NY 10990
Fax: (845) 987-1129
 
 
 
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Dry Eye Questionnaire
   
 
   
 
Try and focus on the black dots

How many legs does the elephant have?

Which center circle is larger?

They are both the same size


 

Do you see a face or an Inuit?

  Are the lines straight or curved?

They are straight

Is this a duck?

or a bunny rabbit?


 

Is the red dot inside or outside?

Near the front or on the side?

  Are these just black splotches?






or will the message give you a lift?

Are the lines straight or curved?

They are straight


 

Is the blue inside or outside?

Near the front or on the side?

  How many colors are there?

Just 2, red & green...really!
Is the square bent?

No
Stare at the center

see your world move
Do you see a vase?

or do you see 2 faces?
Are there grey squares?

No
Do you see a person?

Or the word "Liar"?
Is it a beautiful lady?

or a man with a sax?
The two vertical lines...

...are the exact same size.
The two horizontal lines...

...are the exact same size.
Are the diagonals parallel?

Yes
Is there a triangle?

No
Read Carefully!!

There are 2 "The"s
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Riehle Opticians 104 Main Street Warwick, NY 10990 Phone: (845) 986-5367 Fax: (845) 987-1129

Riehle Opticians proudly serves Warwick, NY and the surrounding areas of Greenwood Lake, Tuxedo Park, Southfields, Walton Park, Monroe, Florida and Pine Island.

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