Life Style Dispensing Form by Optylux


Thank You Optylux Group for giving us this wonderful optical Lifestyle Dispensing Form 

Name: _______________________________________________________    Date:____ _____________________

Email: _______________________ 

Profession/Occupation: ___________________________________________________________________________

Nature of Visit:
  Visual Problem – Specify: ________________________________________________________________________
  Routine exam      First eye exam      Broken/lost eyewear      Want new eyewear

Do you or a family member have any of the following?
  Glaucoma      Cataracts      Hypertension      Diabetes      Macular Degeneration

I currently wear:
  Eyeglasses      Contacts      Sunglasses      Combination

Regarding my current eyewear, I am satisfied with the:
  Vision      Comfort     Look/Style

Regarding my current eyewear, I am dissatisfied with the:
  Vision      Comfort      Look/Style

Please check all that apply:
  I spend a lot of time outdoors.      I have trouble seeing at night.
  My job/lifestyle involves both indoor and outdoor activities.   

  I am uncomfortable with the weight and or thickness of my glasses.
  I am light sensitive, driving in bright sunlight
  partaking in my hobbies   glare bothers me.      I participate in active or competitive sports.
  I have trouble with close work while:      reading      using my computer      partaking in my hobbies
  My current eyewear doesn’t meet my performance needs for work and recreation.

When it comes to my sense of fashion style/image, I consider myself:

Please choose the category that you think most accurately reflects your style image most of the time.
  Fashion Confused
  I consider eyewear just a medical device
  Comfort & vision are all I care about in eyewear.
  I rarely update my wardrobe or change my look.
  Fashion Conservative
  I prefer classic, traditional styles.
  I am not really influenced by fads or trends.
  I feel eyewear should be minimal and subtle.
  Fashion Conscious/Curious
  I have an updated style
  I am interested in new trends.
  I consider my eyewear a fashion/accessory item.
  I believe eyewear should reflect my image.
  Fashion Cutting Edge
  I am a trendsetter and fashion forward.
  I am willing to take risks with my overall look.
  I value and recognize quality brands.
  Accessories are a MUST for me.
  I believe my eyewear should make a statement.

I use a Computer ___ Hours in a day 

I drive ____ Hours in a day. 

I own ___ pair of readers.

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