Your Eye Care Needs Date MM slash DD slash YYYY Patient's Name First Last How many pairs of glasses do you regularly use?Check all that apply: Distance Only Lined bifocals Computer Glasses Reading Only Sunglasses Progressive No-line Multifocals Do you currently have problems with any of the following? Check all that apply: Night Time Glare Bright Sunlight Close-Up Vision for Detail Work Computer Glare Flourescent Lighting Computer Work Do you wear prescription sunglasses? Yes No Are they polarized? Yes No Please check activities that apply to you. Snow Skiing Hiking Public Speaking Soccer Boating Golfing Office Work Softball/Baseball Fishing Tennis Computer Use Football Crafts Gardening Music Jogging Swimming Biking Archery Other If other, please specify:Are you interested in Contact Lenses? Yes No Would you like information on surgical alternatives for Vision Correction? Yes No Do your eyes ever feel or do you experience any of the following? Check all that apply: Gritty or sandy sensation Pain or soreness Fluctuating vision Occasional Tearing Blurred vision while reading Discomfort in windy conditions Discomfort in air conditioned areas Dryness Burning Δ
