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? CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.