THE OPTICAL EXPERIENCE
LIFESTYLE QUESTIONNAIRE
CLIENT INFORMATION
FULL NAME
AGE
VISION PREFERENCES AND NEEDS
Do you have any issues with light sensitivity?
Please Select
Yes
No
Not Sure
Do you play any sports
Please Select
Yes
No
Plan to play soon
If yes, please list sports
What do you do for work?
What do you currently wear?
Please Select
Glasses
Contacts Lenses
Both
Nothing now
What kind of lenses do you currently wear?
Please Select
Single vision
Bifocal ( lenses with line on them)
Trifocal ( lenses with two lines on them)
Progressive
Not sure
What lens options do you currently have on your glasses?
Please Select
Transitions
Anti-Reflective coating
Fog Resistant
Blue light coating/filter
How do you feel about your current glasses and/or contact lenses?
I love them
Ready to update and get a fresh look.
I currently don't wear any correction
I'm not really sure
They are uncomfortable
Other
Are you interested in learning more about different lenses or frame options available?
Please Select
Yes
No
Maybe
Do you experience any eye strain or discomfort after using digital devices?
Please Select
Yes
No
Not sure
Do you spend a lot of time outdoors?
Please Select
Yes
No
Are you exposed to any specific environment that affects your eyes( E.G dry air, high humidity, bright sunlight, heat) ?
Please Select
Yes
No
Not sure
If yes, please list environment(s).
What's your personal style and fashion preferences when it comes to eyewear?
What's your budget for eywear?
Please Select
whatever my insurance covers
$0-$99
$100-$199
$200-$299
$300-$399
$400 and up
Are you open to trying different looks or styles?
Please Select
Yes
No
What colors do you think look best on you?
Please Select
NEUTRALS (E.G., BLACK, WHITE, BEIGE)
BRIGHTS (E.G., RED. BLUE, YELLOW)
PASTELS (E.G., PINK, LAVENDER, MINT)
EARTH TONES (E.G., BROWN, OLIVE, RUST)
How often do you change your hair color?
Please Select
Often
Occasionally
Rarely
Not at all
Do you have any specific brands or material you prefer for your eyewar ( E.G titanium, acetate, eco-friendly options) ?
Please Select
Yes
No
If, yes please list
How important is it for your eyewear to reflect your personality?
Please Select
Very important
Somewhat important
Comfort and fit matter more
How important is it for your eyewear to be lightweight ?
Please Select
Very important
Somewhat important
Comfort and fit matter more
Are you allergic or have sensitivity to any materials ?
Please Select
Yes
No
Not sure
If yes, please list.
Have you had any issues with previous eyewear? ( E.G breakage, damaged lenses, mismatch, discolor, etc.)
Yes
No
If yes, please list.
Are you considering purchasing multiple pair?
Please Select
Yes
No
Not sure
Are you interested in learning about or exploring future options like prescription sunglasses or specialized lenses available?
Please Select
Yes
No
Not sure
20 What did you like most about your last pair of glasses?
What do you value about your lifestyle
Please Select
Flexibility
Structure
Adventure
Simplicity
Would you be interested in receiving updates about new eyewear styles, special promotions and personalized services we offer?
Please Select
Yes, by email
Yes, by text
No
Some,but not all
Are you looking for eyewear that transitions to dark lenses when you go outside?
Please Select
Yes
No
Not sure
What do you want most from your new eyewear?
27 IS THERE ANYTHING ELSE YOUD LIKE TO SHARE THAT WOULD HELP US FIND THE PERFECT EYEWEAR FOR YOU
Submit
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