To provide you with the best vision possible, we need to know a little more about you.  Please fill in the blanks below regarding your vision needs.

Name_______________________________________Date______________________

Are you having Vision difficulties at:  __Work   __School       __Play          __Other ______________ 

Occupation:_____________List your favorite hobbies:__________________________

When spending time?

  Outdoors               Any concerns with:   __Glare       __Sunlight    __Safety       __Health

   Driving                  Any concerns with:  __Glare       __Sunlight    __Night vision

   Playing sports        Any concerns with:  __Safety      __Sunlight    __Durability

   Computer / TV       Any concerns with:  __Glare       __Eyestrain   __Focus 

Are your eyes sensitive to sunlight?                                    __  yes    __  no     

Do you currently have sunglasses?                                      __  yes    __  no      __ Interested

Do you currently wear contact lenses?                                 __  yes    __  no      __ Interested

If you wear contact lenses do you have glasses?                   __  yes    __  no

If you currently wear glasses, what would you change about them?

__ Style          __More comfort           __Thinner Lenses       __Safer          __Lenses that Change Color

         __Sun protection          __Less Glare          __More durable        __Invisible Bifocal

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