Surname               Given Name 
 

Email Address 

Hobbies You Enjoy

Home workshop

Needlework, knitting, etc.

Stamp or coin collecting

Card playing

Computer / computer games /web surfing

Reading

Drawing, painting

Driving

Other

Sports In Which You Participate     

Racquetball, Tennis

Swimming

Scuba

Boating

Hunting, Shooting

Contact Sports – Football

Skiing

Running

Cycling

Golf

Please describe the work that you do

Occupational Needs

Computer terminal

Protective (safety)

Outdoor U.V. protection

Overhead work (wiring, plumbing...)

Other                  

Your Eyewear Needs
 

Daily Wear

Business

Dress Up

Sports

Driving

Reading Only

Multifocal (invisible bifocal)

Sunglasses

Sunglasses that change to clear

Other

If you would like information on the following, please check:

Laser correction

Computer Vision Syndrome

Sun sensitivity

Night driving glasses

Preventative eye care

When you are seen by the doctor, you will be asked about your visual symptoms and your
health history You may take that time to discuss any other visual concerns that you may have.

Thank you