Eyewear Lifestyle Questionnaire Patient Name: __________________________________ Date of Visit:__________________ Occupation:_________________________ Routine Vision Insurance: _________________ This questionnaire is designed to assist your eye care professional in helping you select the lenses and frame/s to suit your visual needs, lifestyle, and help provide you with the best vision possible. Please take a few moments to answer the following questions, you can email this to optical@tceyecenter.com or bring with you to your appointment. 1. Which of the following visual demands do you encounter on a regular basis? (Check all that apply) ___Artificial lighting ___Smart Devices ___Close-up work ___Computer work ___Natural lighting ___Paperwork ___Potential eye hazards ___Reading 2. Which of the following hobbies or activities do you participate in? (Check all that apply) 3. Do your eyes seem bothered by glare from any of the following situations (check all that apply): ___Car Headlights ___Computer Monitor ___Flourescent Lights ___Night Driving ___Haze ___Sunshine ___Traffic Lights ___Other: _______________________ 4. Do you have any metal or silicon allergies? _____ YES _____NO 5. What do you like about your current glasses (color, style, fit, etc.)? ________________________________________________________________________________________________________________________________________________________ 6. What don’t you like about your current glasses (weight, thickness, glare, etc.)? ________________________________________________________________________________________________________________________________________________________ Adapted from VSP: Practice Made Perfect Guide to Eyewear Sales