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This form is vital to assist us to determine the different optical needs in your daily lifestyle.

Which of the following eye symptoms do you experience on a daily basis?*
HeadachesGlare/Light sensitivityDouble visionSore/Tired eyesDry/Watery eyesBlurred visionBurning/Itching/Red eyes


What eye wear are you currently wearing?*
No Visual aidsSingle vision for distanceSingle vision for readingBifocal lensesMultifocal/Progressive lensesOffice ComputerSports prescriptionPrescription sunglassesEye lubricantsContact lensesSafety prescription eye wear


Please tick any of the below that apply to you:*
Have trouble seeing at nightEyes are sensitive to reflection off water surfacesStruggle to see far/watching TV/reading traffic signsMy eyes are sensitive to lightImpact chemical environmentI struggle to read near/reading on my cell phone


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