Brooks Eyecare Center

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Brooks Eyecare Mission Statement

Our Mission is to be the premier facility in Kentucky; delivering the highest quality care using the latest in technology and treatment protocols; providing that care with a friendly, knowledgeable, and caring staff.

Patient Lifestyle Questionnaire

Date:

Patient Information

Patient Name:

Phone:

Email:

Survey

I currently wear:

Eyeglasses

Contacts

Sunglasses

Combination

Regarding my current eyewear, I am Satisfied with the:

Vision

Comfort

Look/Style

Regarding my current eyewear, I am Dissatisfied with the:

Vision

Comfort

Look/Style

Please check all that apply:

	I spend a lot of time outdoors.
	I have trouble seeing at night.
	My job/lifestyle involves both indoor and outdoor activities.
	I am uncomfortable with the weight and/or thickness of my glasses .
	I am light sensitive, driving in bright sunlight and glare bother me.
	I have trouble with close work while:
	Reading Using my computer Partaking in my hobbies
	I participate in active or competitive sports.
	My current eyewear doesn't meet my performance needs for work and recreation.

When it comes to my sense of fashion style/image, I consider myself:

(please choose the category below that you think most accurately reflects your style image most of the time)

Fashion Confused

I consider eyewear just a medical device
Comfort and vision are all I care about in eyewear
I rarely update my wardrobe or change my look

Fashion Conversative

I prefer classic, traditional styles
I am not really influenced by fads or trends
I feel eyewear should be minimal and subtle

Fashion Conscious/Curious

I have an updated style
I am interested in new trends
I consider my eyewear a fashion/accessory item
I believe eyewear should reflect my image

Fashion Cutting Edge

I am a trendsetter and fashion forward
I am willing to take risks with my overall look
I value and recognize designer brands
Accessories are a MUST for me
I believe my eyewear should make a statement