The Patient Questionnaire

This questionnaire was developed to assist us in helping you choose the frame and lenses best suited to your particular needs.
Please check the sections that apply to you.

Personal Information Name____________________________________________________________

Address__________________________________________________________________________

City______________________________________________________________________________

State/Province__________________________________________________Zip_________________

Phone____________________________________________________________________________

1. Does your job require you to wear protective eyewear? __Yes __ No
2. Who is your employer? ____________________________________________
3. Do you currently use more than one pair of glasses? __Yes __ No
4. If so, is your second pair for a special application such as (check all that apply):

__ Protective eyewear for work __ Protective eyewear for home __
Prescription sunglasses  Other_____________________________________________________
5. Do you know the difference between dress eyewear and safety eyewear? __Yes   __ No
6. Do your home maintenance activities or hobbies include (check all that apply):
       __ Gardening     __ Woodworking     __Yard work      __Auto repair     __Painting
       __ Using power tools     __Using caustic cleaning supplies    Other:________________________
7. Do the following activities affect you?
       ___ Night driving   ___ Computer usage  ___ Ultraviolet (UV) exposure   ___ Close-up work
8. Do you wear contact lenses? __Yes   __ No
9. What is the most hazardous thing you do that could cause an eye injury (at work or outside the work place)? Please describe_________________________________________________________
10. If you had a comfortable and attractive pair of glasses for special applications such as woodworking,
    would you wear them?
         __Rarely    __Sometimes  __Never
11. How important is the cost factor in buying protective eyewear?
          __Primary consideration    __Reasonably important   __Not a factor

The importance of wearing protective eyewear, while participating in home and recreational activities that
are potentially hazardous to my vision, has been explained to me. __Yes   __ No

   __ It has     __ It has not been recommended that I wear protective eyewear for my special activities.
   __ I have  __ I have not selected protective eyewear for my personal use.

Patient Signature:_______________________________________________

Date__________________________

A note to eyecare professionals . . .

Titmus has provided this form for your use. Please feel free to copy and use it to screen your patients.
It is advised that you keep a copy in your patient's files.