基本資料Basic Information

1. 您的姓名 (必填)1. Full Name (Required)

2. 聯絡電話 (必填)2. Phone Number (Required)

電子郵件 (必填)Email Address (Required)

3. 性別3. Gender

4. 年齡4. Age

5. 職業 / 目前工作形態5. Occupation / Work Style

眼鏡配戴歷史與習慣Visual History & Habits

6. 您目前主要配戴的光學輔具有哪些？(可複選)6. Current optical aids? (Multiple)

一般單焦點眼鏡（看遠用）Single vision glasses (Distance) 看近專用眼鏡（老花眼鏡）Reading glasses 多焦點 / 辦公室型 / 舒壓鏡片Progressive / Office / Anti-fatigue lenses 軟式隱形眼鏡（一般 / 散光）Soft contact lenses 硬式隱形眼鏡 / 角膜塑型片RGP / Ortho-K lenses 完全沒有配戴眼鏡 / 有度數但是平常不戴眼鏡No glasses / Rarely wear them

7. 承上題，您目前的眼鏡大約配戴了多久？7. How long have you worn your current glasses?

8. 平均一天的「螢幕使用時間」多長？8. Average daily screen time?

9. 是否曾接受過眼科手術（如雷射、白內障等）？9. Any eye surgeries? (e.g. LASIK, Cataract)

10. 個人內科病史紀錄 (可複選)10. Medical History (Multiple)

醫療保密宣言：此健康資訊僅供神經視覺評估之臨床參考，受嚴格隱私保護。 Medical Confidentiality: Information used strictly for clinical assessment and protected by privacy protocols.

高血壓Hypertension 糖尿病Diabetes 心血管疾病Cardiovascular Disease 眩暈 / 前庭系統異常Vertigo / Vestibular Issues 甲狀腺功能異常Thyroid Dysfunction 免疫系統相關疾病 (如乾燥症、紅斑性狼瘡等)Autoimmune Disease 以上皆無None of the above 其他 (請在下方說明)Other (Specify below)

主觀視覺不適Subjective Visual Symptoms

11. 【清晰度與對焦】常遇到以下狀況嗎？(可複選)11. [Clarity & Focus] Common issues? (Multiple)

看遠沒問題，看近距離會比較模糊，需要拿遠一點才看得清楚Clear far, blurry near (need to hold further) 看近一段時間後抬頭，看遠會暫時性模糊（對焦變慢）Slow focus when looking far after near work 覺得目前眼鏡度數似乎不夠，看不清楚Current glasses feel too weak 覺得目前眼鏡度數似乎太深，戴久會頭暈或有壓迫感Current glasses feel too strong/cause pressure

12. 【雙眼協調與空間感】是否有以下困擾？(可複選)12. [Binocular & Depth] Issues? (Multiple)

偶爾會看到兩個影子（複視）Occasional double vision 閉上一隻眼睛時，反而覺得看得比較清楚或舒服More comfortable when closing one eye 開車、運動時，覺得判斷距離感/立體感有困難Difficulty judging depth/distance 很容易撞到桌角或門框Easily bump into corners/doors

13. 【深層疲勞與身體代償】長時間用眼後會出現？(可複選)13. [Fatigue & Compensation] Symptoms? (Multiple)

眼睛容易酸澀、流眼淚或覺得脹痛Eyes feel dry, sore, or watery 經常伴隨頭痛（眉間、眼眶或後腦勺）Frequent headaches (between brows, eyes, back of head) 肩頸極度緊繃，甚至需要經常按摩Extreme neck/shoulder tension

14. 【閱讀習慣】閱讀文字時是否有以下習慣？(可複選)14. [Reading Habits] Behaviors? (Multiple)

容易跳行、漏字，需要用手指輔助閱讀Skip lines/miss words, need finger guidance 閱讀一小段時間後，專注力就大幅下降Focus drops significantly after short reading 閱讀時，頭部會不自覺地歪向某一側（歪頭）Unconsciously tilt head while reading

15. 【光線敏感度】對於周遭光線是否容易不適？(可複選)15. [Light Sensitivity] Issues? (Multiple)

白天出門覺得陽光刺眼，必須戴墨鏡Sunlight is glaring, need sunglasses 夜間開車時，對向車燈讓您非常眩光不適Severe glare from headlights at night 長時間看電腦或手機螢幕，覺得特別刺眼疲勞Screens feel especially glaring/tiring

預約時段與確認Booking & Confirmation

16. 請簡述您目前「最希望改善」的視覺困擾 (必填) 若無請填無16. Your main visual goal? (Required. If none, enter "none")

17. 認識凡特錫的管道？17. Referral Source?

18. 其他想讓驗光師提前了解的事項？18. Any other notes for the optometrist?

19. 請填寫 2-3 個理想預約日期與時間 (必填)19. 2-3 preferred dates/times (Required)

20. 我已了解凡特錫眼鏡以提供完整視覺解決方案為主，因臨床評估需耗費大量專業時間，恕不提供「單純商品比價」或「僅索取驗光處方」之服務。且同意表單資料僅供臨床評估使用。(必填) 20. I understand Fantastic Vision focuses on comprehensive visual solutions. Due to the professional time required, we do not offer price-matching or prescription-only services. I consent to my data being used for assessment. (Required)

深度視覺評估預約單 In-Depth Vision Assessment Form

基本資料Basic Information

眼鏡配戴歷史與習慣Visual History & Habits

主觀視覺不適Subjective Visual Symptoms

預約時段與確認Booking & Confirmation