Lifestyle Questionnaire - Ophthalmology Eye Associates of NC

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Date:

Check the following activities you need glasses to do:

On a scale of 1-10, with 1 being "Easy Going" and 10 being "Perfectionist", how would you best describe your personality?

Do you wear glasses now?

If Yes:

How important is it for you to read or use the computer without glasses?

How many hours per day do you read?

How many hours per day do you use the computer?

Where do you hold your book when reading?

If it were possible to go without glasses most of the time, would you like that?

Do you drive at night?

If Yes:

What other activities do you currently engage in:

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