CLEAR LAKE OPTOMETRY - LIFESTYLE QUESTIONNAIRE

Note to patients: This questionnaire was created to assist your eye care professional in helping you choose the eye wear best suited to your particular needs and lifestyle concerns. Please take a moment to answer all of the questions that apply to you.
You may print this form using the print function of your browser and bring it with you on your next visit.

Personal Information

Name:
Address:
City:
State:Telephone:
Zip:
  1. What do you like about your current pair of glasses?
  2. What don't you like about your current pair of glasses?
  3. Do your home maintenance activities include: (check all that apply)
    gardening/landscaping
    woodworking/sawing
    yard work
    auto repair
    painting
    use of power tools
    use of chemicals and caustic materials
    other
  4. What are your favorite hobbies/recreational activities: (check all that apply)
    cards/bingo/board games
    computer
    sewing/needlepoint
    fishing/boating/water sports
    golf
    tennis
    woodworking
    gardening
    spectator sports
    other
  5. Are you bothered by glare from any of the following:
    night driving/headlights
    sunshine/UV exposure
    haze
    fluorescent lights
    computer screens
    other
  6. Does your work entail unusual visual demands due to any of the following:
    distance
    near viewing
    position
    natural or artificial lighting
    abrupt changes in light levels
    other
  7. Do you wear contact lenses? Yes:  No:
  8. Do you currently use more than one pair of glasses? Yes:  No:
  9. If so, state whether you use your second pair of glasses for a particular reason: (check all that apply)
    hobby/recreational activity
    sports/protective eye wear
    when driving a car
    prescription sunglasses
    occupational eye wear
    reading glasses
    evening/comfort wear
    fashion wear
    other
  10. What is potentially the most hazardous activity you participate in on a regular basis, either at work or outside the workplace?
  11. Patient Signature:


Thank you! Dr. Anderson will take your responses into consideration when recommending the right eye wear for you.