Lifestyle Vision Questionnaire

 

Name: Date:

We recognize that your eyes are very important to you. We would like to konow you use your eyes on a daily basis. Along with your eye exam, this info will assist us in recommending the best options for your eyes and your personal lifestyle vision.

Do you wear glasses now?

If Yes :

How important is it for you to see to read or use computer without glasses?

If it were possible to go without glasses for most of the time, would you like that?

How many hours per day do you read?

use computer ?

Do you drive at night?

Check the following activities you do on a regular basis:

Shop
Cook
   

What occupational, recreational, or other activities do you currently engage in that are not listed above?

Please place an "X" on the following scale to describe your personality as best you can:

Easy Going Perfectionist
 

REV 5/2013