Visit Our Positive Eye Ons Website
(310) 796-5665
(866) 306-1450
Book an Appointment
Text
Call
Book

Neurolenses Questionnaire

(866) 306-1450
Book an APpointment

Neurolenses 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.

Patient Details

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.
Untitled(Required)

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).
Untitled(Required)

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).
Untitled(Required)

Tired Eyes*

Your eyes feel increasingly fatigued/tired as the day goes on.
Untitled(Required)

Dry Eye Sensation*

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

Light Sensitivity*

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

Dizziness*

You experience dizziness, motion sickness, or vertigo.
Untitled(Required)

Additional Notes

Any additional notes you'd like to add: