Our office recommends employees bring this vision information form to their examining doctor to ensure he or she has all the data necessary to formulate the most precise prescription for all job activities.
What I do with my Eyes
1. Complete the questions on this form
2. Bring the completed form to your eye doctor
Describe the type of work you do with your eyes. Examples: machine operator, assembler, computer user.
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Describe the size & type of printed materials you work with . (Bring an example with you to the doctor’s office if you wish)
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How far away exactly do you work from your job responsibilities? ( You can measure this distance by using a measuring tape from the bridge of your nose)
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Show your eye doctor what a comfortable distance for reading is best for you.
Describe the type of lighting in your work area. Please advise the doctor of any prescription or over the counter medication you take regularly.
Do you have any current difficulties with your current glasses? Current prescription? Are dry eye symptoms affecting your eyes comfort and vision? Y N
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Please describe the most hazardous activity in the course of your regular job responsibilities which could cause an eye injury
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Are you requesting permission to wear contact lenses at your place of employment? Y N Do you have trouble seeing certain colors? Y N
Employee Name _________________________________________________ date________________
Dr. Signature
Is the doctor recommending a change in your prescription? Yes_____ No______
Doctor recommends the following lens treatments due to eye health/prescription:___________________________________________________________________