EYE WELLNESS OPTOMETRY: DR.TONY D. VU AND DR. KARISSA DO
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Our Practice
Meet The Doctors
Meet The Staff
Order Contact Lenses
Our Services
Patient History Form
Patient Lifestyle Questionnaire
Insurances
Financing Option
Yelp Us
Testimonials
Patient Education
Your Progressive Lenses
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YOUR CART
Life Style Questionnaire
Thank you for taking a few minutes to complete this questionnaire. The information you provide will help us better understand your vision care needs.
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Indicates required field
What is your professional environment?
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I work in a professional business office.
I work from home.
My job requires travel (driving/flying/both).
I work outside most of the time.
Other
Please choose one.
If Other please specify:
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How much time do you spend each day at the computer?
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0-1 hour
1-3 hours
3-5 hours
5-8 hours
8+ hours
Please choose one.
How much time do you spend driving at night?
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Rarely
Sometimes
A lot
Please choose one.
What are you indoor activities? (Check all that apply)
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Reading
Arts/Crafts
Sewing/Knitting
Computer gaming / Video game consoles
Other
Check all that apply.
If Other please specify:
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What type of outdoor activities do you participate in? (Check all that apply)
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Baseball / Basketball / Football
Cycling
Gardening
Golfing
Fishing/ Boating
Gardening
Tennis
Swimming
Volleyball
Walking / Jogging / Hiking
Other
Check all that apply.
If Other please specify:
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Name
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First
Last
Email
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Phone Number
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