Quality of Vision Checklist

Quality of Vision Checklist
This checklist will assist us in providing the best quality of care and customized vision solutions that are best suited for your visual needs and lifestyle.
Name*
Age*
Do you wear glasses?*

YesNo
Contacts?*

YesNo
If yes

Only for drivingOnly for readingOnly for computer workAll the timeSometimes
Would you like to be less dependent on glasses/contacts?

YesNo
What is your profession?*
What hobbies/activities do you have difficulty with even with glasses? (check all that apply)

Reading/small print/labelsWriting checks/filling out forms sewing/knitting/carpentryPlaying cards/gamesUse the computer/tabletSeeing steps or curbsDriving / street signsWatching TV/ moviesGolfing/hunting/sportsOther
Do you experience glare and or halos around lights at night?

YesNo
On a scale of 1 – 10, how would your best friend describe your personality? *

1

2

3

4

5

6

7

8

9

10

1 is Easy Going, 10 is Detail Oriented
Signature

Clear
Should be Empty: