Visual Lifestyle Questionnaire

Visual Lifestyle Questionnaire
Please tell us how you use your eyes in the pursuit of your lifestyle.
Name*

First NameLast Name
Date*

MonthDayYear
Date
What is your occupation?
Hours A Day On Technology?
Check All That Apply

DesktopIpadLaptop/Smart PhoneBook Or Newspaper
What Type Of Vision Correction Do You Currently Use ? (Check All That Apply)

Prescription GlassesPrescription SunglassesNon-Prescription SunglassesReaders/CheatersPolarized LensesNon-Glare TreatmentTransition Lenses
Do you wear contact lenses?
If no, are you interested in wearing them?
How Far Is The Reading Or Close Work Material From You? (Check All That Apply)

12-14 Inches (holding a book or sheet of paper)16-24 Inches (arm's length)Further than 24 inches, but less than 20 feet
How Would You Describe The Lighting Where You Do Most Of Your Reading?

LowAdequateBrightContrastGlare
Do You Experience Back, Neck Or Shoulder Discomfort While Using A Computer?
Have You Ever Experienced Any Issues With Glare Or Eye Strain In The Day Time, Night Time (Halos Around Headlights) Or While Using Technology?
What activities or hobbies do you engage in? (Check all that apply)

ReadingPaintingSewing/NeedlecraftsGardeningWalking/Running/CyclingWorkshopMotorcycleShooting/HuntingFishingFlyingOutdoor SportsIndoor SportsVideo GamingTravelingOther
Other:
Should be Empty:

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