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.

Lifestyle Index

How often do you experience any of these symptoms? Choose applicable circle.
1 = Never
2 = Rarely
3 = Sometimes
4 = Very Often
5 = Always

​​​​​​​Headaches of any severity each week, usually getting worse later in the day*
Stiffness/pain in neck/shoulders when you work at a computer or read
Discomfort with Computer Use in your eyes (redness, burning) after long hours looking at the screen
Tired Eyes with increasing feeling of eye fatigue throughout the day
Dry Eye Sensation feeling progressively more gritty/sandy while working at computer or reading
Light Sensitivity especially with brighter, stronger lights like fluorescents or headlights
Dizziness or an experience like motion sickness or vertigo

Add your name, phone number and email address to see your results

New or returning patient?

admin none 9:00 AM to 6:00 PM 9:00 AM to 7:00 PM 9:00 AM to 6:00 PM 9:00 AM to 7:00 PM 9:00 AM to 1:00 PM By Appointment only Closed Optometrist # # #