Lifestyle Questionnaire
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Today's Date
*
-
Month
-
Day
Year
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Occupation:
Computer use per day:
*
< 2 Hrs
2 - 6 Hrs
> 6 Hrs
Do you use a tablet or smartphone?
*
Please Select
Yes
No
Hobbies / Activities:
Baseball
Basketball
Biking
Football
Golf
Tennis
Racquetball
Running
Shooting/Hunting
Skiing
Soccer
Swimming
Volleyball
Crafting
Hiking
Fishing
Motorcycle
Music
Painting
Reading
Travel
Video Gaming
Woodworking
Yard Work
How many pairs of eyeglasses do you currently own?
*
Are you interested in wearing contact lenses?
*
Please Select
Yes
No
I am currently a contact lens wearer
Please list any issues you have had with your vision while driving:
Please list any trouble with past eyeglasses:
What is important to you regarding your eyeglasses?
*
Comfort
Back up pair
Thin lenses
Updating your look
Optimized vision
Glare reduction
Latest lens technology
Eyewear wardrobe (work, evening, suns)
Melanoma prevention
Price
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