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Home » Visual Needs Assessment

Visual Needs Assessment

Your Name*
First Last
Email*
Occupation*
Are you bothered by glare from any of the following?
*Select all that apply
- Night driving
- Sunshine
- Fluorescent lights
- Computer screens
Hobbies?
*Select all that apply
- Golf
- Sewing
- Fishing/Hunting
- Hiking/Biking
- Skiing
- Reading
- Cycling
How many hours per week do you spend:
On a computer
- 0-10 hours
- 11-20 hours
- 20+ hours
Outdoors
- 0-10 hours
- 11-20 hours
- 20+ hours
Daytime Driving
- 0-10 hours
- 11-20 hours
- 20+ hours
Nighttime Driving
- 0-10 hours
- 11-20 hours
- 20+ hours
Participating in Hobbies
- 0-10 hours
- 11-20 hours
- 20+ hours
Check all that apply:
- I read a lot of small print
- My eyes are sensitive to sunlight
- I perform fine/close-up work
- I have trouble reading
- Safety protection is a concern for my eyewear
- I have trouble reading signs at night while driving
- I have prescription sunglasses
- I would be interested in prescription sunglasses
How many pairs of glasses do you currently use?
What do you like most about your current glasses?
What do you like least about your current glasses?
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Fallston Eye Care

1800 Harford Rd.
Fallston, MD 21047

Phone: 410-877-9000
Email: fallstoneyecare@gmail.com
(Do not send personal health information by email.)
Fax: 410-885-6558

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: 9:00 AM - 6:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 3:00 PM
Saturday: Closed
Sunday: Closed

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Fallston Eye Care - Located at 1800 Harford Rd., Fallston, MD 21047 Phone: 410-877-9000 www.fallstoneyecare.com

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