Visual Assessment – McPherson Family Eye Care

First Name

Last Name

Email*

Occupation

Are you bothered by glare from any of the following?

*Select all that apply

Do you have any of these hobbies?

*Select all that apply

How many hours a week do you spend:

On a computer:

Outdoors:

Daytime Driving

Nighttime Driving

Participating in Hobbies:

General Eye Concerns:

*Select all that apply

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

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?

Phone

This field is for validation purposes and should be left unchanged.