Vision Questionnaire Answer these vision related questions and we will contact you with how we can help. Are you interested in seeing well in the distance without glasses?YesNoAre you interested in seeing well at near (arms length and within) without glasses?YesNoWhat near vision hand/eye activities do you enjoy or perform often? Carpentry Cooking Driving Gardening Needle point/knitting/crocheting Painting Piano/organ/music Playing Cards Puzzles (crossword, general, etc.) Reading Use a Cell Phone Other What activities do you enjoy / perform often? Biking Bowling Third Choice Computer Work Golfing Driving Fishing Hunting Shopping Swimming Tennis Time with kids Traveling Watching TV Writing Other How enjoyable would it be for you to be free from glasses for all your daily activities?Very EnjoyableEnjoyableSomewhat EnjoyableDoesn’t MatterDo you do a lot of night driving?YesNoSomewhatDo you use a computer on a daily basis?YesNoSomewhatHow would you describe your personality?Easy GoingPerfectionistIn between the twoPlease tell us about any other quality of life vision concerns that you have: Name First Last Email PhoneCommentsThis field is for validation purposes and should be left unchanged.