Burnt Hills Optical Page 2
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3Last Name_________________________________ First Name__________________________________ MI_______
Your Vision Lifestyle
Please check how often you currently wear the following forms of sight correction and/or sight protection.
Glasses
Always
Often
Rarely
Never
Contact lenses
Always
Often
Rarely
Never
Non Prescription Sunglasses
Always
Often
Rarely
Never
Prescription Sunglasses
Always
Often
Rarely
Never
Safety or Sport Eyewear
Always
Often
Rarely
Never
Please check your participation level in the following activities and indicate whether or not use your eyewear for that
activity.
I Use eyewear for this activity:
Reading
Frequently
Infrequently
Yes
No
Computer Use
Frequently
Infrequently
Yes
No
Television
Frequently
Infrequently
Yes
No
Driving
Frequently
Infrequently
Yes
No
Sports (please specify____________)
Frequently
Infrequently
Yes
No
Other: _______________________
Frequently
Infrequently
Yes
No
Do you currently experience any of the following problems with your current eyewear?
Too Heavy
Always
Often
Rarely
Never
Poor fit or wrong size
Always
Often
Rarely
Never
Difficulty with bifocal
Always
Often
Rarely
Never
Too much glare
Always
Often
Rarely
Never
Need for constant adjustment
Always
Often
Rarely
Never
Do You:
Spend a lot of time outdoors
Yes
No
Currently have prescription sunwear
Yes
No
Want information on laser vision correction
Yes
No
Currently have computer eyewear
Yes
No
Wear bifocals
Yes
No
Think you would benefit from thinner, lighter lenses
Yes
No
Have/have interest in "no line" bifocals/progressive lens
Yes
No
Have interest in transitions lenses
Yes
No
Have an interest in being fit for contact lenses
Yes
No
Yes
No
Do you have any other visual needs you would like us to address?
If so, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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