Visual Needs Assessment Form

Full Name*

First Last

Email*

Enter Email Confirm Email

Occupation*

If other:*

Are you bothered by glare from any of the following?

*Select all that apply

Hobbies?

*Select all that apply

If other*

How many hours per week do you spend:

On a computer*

Outdoors*

Daytime Driving*

Nighttime Driving*

Participating in Hobbies*

General Eye Concerns

Check all that apply:

Are you interested in, or have you worn, glasses in the sunlight?*

If yes, are they polarized?*

How many pairs of glasses do you currently use?*

What do you like most about your current glasses?

What do you like least about your current glasses?