Lifestyle Vision Questionnaire
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? Yes No
If Yes : All the time Sometimes Only for distance Only for reading Only for computer
How important is it for you to see to read or use computer without glasses?
Very important Important Somewhat important Not important
If it were possible to go without glasses for most of the time, would you like that?
Yes No
How many hours per day do you read?
Do you drive at night? Socially Occasionally As profession
Check the following activities you do on a regular basis:
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:
REV 5/2013