Lifestyle Analysis

Full Name

Profession

Email Address

Contact Number

Nature of Visit

Routine exam

First eye exam

Broken eyewear

Visual problem

Do you or a family member have any of the following?

Glaucoma

Cataracts

Hypertension

Diabetes

I currently wear

Spectacles

Contact lenses

Sunglasses

Combination

Please tick applicable box/es

I spend a lot of time outdoors

I have trouble seeing at night

I am uncomfortable with the weight and or thickness of my glasses

I am very light sensitive and glare bothers me

I participate in active or competitive sports

I have trouble with close work while reading

I have trouble with close work while working on the computer

My current eyewear does not meet my work and recreation needs

When it comes to fashion, I consider myself

Fashion confused

Fashion conservative

I prefer classic, trendy style

I feel eyewear should be minimal and subtle

I am interested in new trends

I value and recognize quality brands

I believe my eyewear should make a statement

When looking close by, please give an example of what you are struggling to see, e.g the letters on the computer

Which of the following is it?

When you look far, can you give an example what you struggle to see, eg. the letters on the TV, oncoming cars?

Which of the following is it?

Are you driving mostly long distance or mostly in town, or both?

Does the sun often bother you when you drive?

Are you often driving at night?

Do you wear your glasses at home or during social events, or only when you need them for special tasks?

I use a computer _____ hours per day

I own _____ pairs of reading glasses

I drive _____ hours per day

I own _____ pairs of spectacles

I own _____ pairs of sunglasses

Do you sometimes feel dizzy?

Does your work environment tend to cause your specs to become dirty?

Does your work environment cause a lot of facial sweating?

Does it bother you if you see reflection in your specs?

Do you bump into things when walking, especially at night?

Does your work environment tend to cause your specs to scratch?

Does is bother you if your lenses look dirty to other people?

I love my current specs, because...

I hate my current specs because…

Sort in order of importance to you. 1 = Most Important, 4 = Least Important
Please Note: You can only use a number once

Quality of Frame

Quality of Sight

Fashion of Frame

Economical Price

Please select the one that is applicable to you

I prefer a quality frame that last many years

I would prefer cheaper, frequent replacement specs, so I can have one for every occasion, e.g one for work and one for church and one for sports

I am worried about my eyes because

Did a friend refer you to us?

Do you want us to determine your medical aid benefit?

Do you want to nominate someone that struggles to afford glasses? Enter their name and number and we will test them for free.

Name of person

Contact number of person

Are you suffering of chronic gastritis or any other stomach ailment?

How stressed are you?

1: No Stress | 10: Very Stressed

Do you want to fill in the stress test?: CLICK HERE

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