Visual Needs Assessment Form Name* First Last Email* Occupation*Are you bothered by glare from any of the following? Night driving Sunshine Fluorescent light Computer screen *Select all that applyHobbies? Golf Sewing Fishing/Hunting Hiking/Biking Skiing Reading Cycling Other *Select all that applyIf other*How many hours per week do you spend:On a computer0-1011-2020+Outdoors0-1011-2020+Daytime Driving0-1011-2020+Nighttime Driving0-1011-2020+Participating in Hobbies0-1011-2020+General Eye ConcernsCheck all that apply: Read small print at work Eyes sensitive to sunlight Perform fine or close-up work Have trouble reading Safety protection is a concern Have trouble reading signs at night while driving Have prescription sunglasses? Are you interested in, or have you worn, glasses in the sunlight?YesNoHow many pairs of glasses do you currently use?*0123+What do you like most about your current glasses?What do you like least about your current glasses?
