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Visual Needs Assessment Form
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Visual Needs Assessment Form
Full Name
*
Email
*
Occupation
*
Accounting/Finance
Advertising/Public Relations
Aerospace/Aviation
Arts/Entertainment/Publishing
Automotive
Banking/Mortgage
Business Development
Business Opportunity
Clerical/Administrative
Construction/Facilities
Consumer Goods
Customer Service
Education/Training
Energy/Utilities
Engineering
Government/Military
Green
Healthcare
Hospitality/Travel
Human Resources
Installation/Maintenance
Insurance
Internet
Job Search Aids
Law Enforcement/Security
Legal
Management/Executive
Manufacturing/Operations
Marketing
Non-Profit/Volunteer
Pharmaceutical/Biotech
Professional Services
QA/Quality Control
Real Estate
Restaurant/Food Service
Retail
Sales
Science/Research
Skilled Labor
Technology
Telecommunications
Transportation/Logistics
Other
If other:
*
Are you bothered by glare from any of the following?
*Select all that apply
Night driving
Sunshine
Fluorescent lights
Computer screen
Hobbies?
*Select all that apply
Golf
Sewing
Fishing/Hunting
Hiking/Biking
Skiing
Reading
Cycling
Other
If other
*
How many hours per week do you spend:
On a computer
*
0-10
11-20
20+
Outdoors
*
0-10
11-20
20+
Daytime Driving
*
0-10
11-20
20+
Nighttime Driving
*
0-10
11-20
20+
Participating in Hobbies
*
0-10
11-20
20+
General Eye Concerns
Check all that apply:
Read small print at work
Eyes sensitive to sunlight
Perform fine or close-up work
Have trouble reading
Safety protection is a concern
Have trouble reading signs at night while driving
Have prescription sunglasses?
Are you interested in, or have you worn, glasses in the sunlight?
*
Yes
No
If yes, are they polarized?
*
Yes
No
How many pairs of glasses do you currently use?
*
0
1
2
3+
What do you like most about your current glasses?
What do you like least about your current glasses?
Office Hours
Mon
day
9:00am
4:00pm
Tues
day
9:00am
4:00pm
Wed
nesday
9:00am
4:00pm
Thurs
day
9:00am
4:00pm
Fri
day
9:00am
4:00pm
Sat
urday
Closed
Sun
day
Closed
Interactive Eye
At JEMS Optical, we believe it is important to keep our patients educated about healthy vision. Learn more about the anatomy of your eye with our Interactive Eye!
Click and learn more
.
Special Offer
20% OFF Total Purchase, Including Exam.
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