LIFESTYLE AND CONTACT LENS QUESTIONNAIRE Patient's Name First Last GENERAL VISUAL DISCOMFORT*I am concerned about….* Night Vision Sunshine Computer Glare Difficulty reading or doing fine print work? Difficulty reading computer or at arms length? Difficulty seeing street signs/T.V.? EYEWEARAre you satisfied with the way your glasses look/feel? Are you satisfied with the vision/comfort? Do you wear sunglasses/Polarized? I AM INTERESTED IN No line Bifocals (Progressives) Sunglasses/Polarized Lenses to Reduce Glare (Anti-Reflective) Lighter, Thinner Lenses (Polycarbonate) Self-darkening Lenses (Transitions) OCCUPATIONAL NEEDS/HOBBIESWhat is your occupation? How many hours a day are you on digital devices? Do you work with solvents, paint, dust, or welding? Outside? What are your hobbies/sports? How many hours do you drive daily? CONTACT LENS QUESTIONNAIREWhat brand contact lenses do you wear? How old is this pair? How often do you change out your lenses (for new pair)? Do you sleep in your contacts? Yes No If yes, how many nights/row? What brand contact lens solution do you use? Patient Signature:Date MM slash DD slash YYYY CAPTCHA