Please fill out the appropriate sections.

Frequent computer user:

How long do you spend at the computer each day? 0 hours 1 hours 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12 hours 13 hours 14 hours 15 hours 15 hours 16 hours 17 hours 18 hours 19 hours 20 hours 21 hours 22 hours 23 hours 24 hours

How far away are you from the computer screen? Not Sure 4 inches 6 inches 8 inches 10 inches 12 inches 14 inches 16 inches 18 inches 20 inches 22 inches 24 inches 26 inches 28 inches 30 inches 32 inches 34 inches 36 inches Not Sure

Do you wear glasses? Yes No If Yes what type? Type Single vision Bifocal Trifocal No-line reading

Do you have vision problems with your glasses at the computer? No Yes

Do you wear contacts? No Yes

Do you have problems with contact lens comfort at the computer? No Yes

Currently wears glasses:

Do you currently wear glasses? No yes Time worn? 1 Year 2 Years 3 Years 4 Years 5-10 Years 10-20 Years 20-30 Years 30-40 Years 40-100 Years

Type of glasses? Type Single vision Bifocal Trifocal No-line reading Worn? Full-time Part-time For? Distance Close

Glasses Owned? (Check all that apply.)	:Single Vision
:BiFocals	:TriFocals
:Progressive	:Back-Up
:Safety	:Sports

Do you drive? Yes No

Do you have visual difficulty when driving? Yes No

Do you have glare problems? Yes No

Do you have problems with night vision? Yes No

Have you had trouble in the past with glasses? Yes No

If Yes, what trouble?

Do you wear sunglasses? Yes No

Are your sunglasses your current prescription? Yes No

Currently wears contact lenses or are interested in wearing contact lenses:

If not a contact lens wearer, are you interested in trying contact lenses at this time? Yes No

Have you ever tried to wear contact lenses? Yes No

Reason for stopping?

Do you currently wear contact lenses? Yes No Time worn? 1 Year 2 Years 3 Years 4 Years 5-10 Years 10-20 Years 20-30 Years 30-40 Years 40-100 Years

Type and brand of contact lenses?

Today’s wearing time? 0 hours 1 hours 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12 hours 13 hours 14 hours 15 hours 15 hours 16 hours 17 hours 18 hours 19 hours 20 hours 21 hours 22 hours 23 hours 24 hours

How many hours per day? 0 hours 1 hours 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12 hours 13 hours 14 hours 15 hours 15 hours 16 hours 17 hours 18 hours 19 hours 20 hours 21 hours 22 hours 23 hours 24 hours

Lens Comfort 1-Poor 2 3 4 5-Average 6 7 8 9 10-Excellent - Distance Vision 1-Poor 2 3 4 5-Average 6 7 8 9 10-Excellent - Near Vision 1-Poor 2 3 4 5-Average 6 7 8 9 10-Excellent

Cleaner:

Disinfectant:

Enzyme:

Special vision needs for work, sports, or hobbies:

Are you a frequent computer user? Yes No

Do you experience visual discomfort while at the computer? Yes No

Do you do a lot of yard work, carpentry, or painting? Yes No

Do you work with a lot of machinery, or have any specific visual/glasses needs for your job? Yes No

What activities do you enjoy in your spare time?