Neurolens Questionnaire

Neurolens Questionnaire

Neurolens Questionnaire

Neurolens Questionnaire

Lifestyle Index

This questionnaire is meant to help your doctor understand what you’re experiencing on a regular basis — whether it’s caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

Click here to download the form


Patient Details

Name:

Phone Number:

Email:

How often do you experience any of these symptoms? Choose the applicable option.

Headaches

  • You get headaches of any severity each week (even just a dull ache counts).

  • Your headaches tend to get worse later in the day.

Stiffness / pain in neck / shoulders

You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).

Discomfort with Computer Use

You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).

Tired Eyes

Your eyes feel increasingly fatigued/tired as the day goes on.

Dry Eye Sensation

Your eyes progressively feel more dry/sandy/gritty while working at the computer or reading.

Light Sensitivty

Bright / Strong lights (vehicle headlights, florescent lights etc.) bother you.

Dizziness

You experience dizziness, motion sickness, or vertigo.

Additional Notes

Any additional notes you'd like to add:

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