Lifestyle Index Form

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. How often do you experience any of these symptoms? Choose the applicable answer.
Your Full Name*
Headaches*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Stiffness/pain in neck/shoulders*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Discomfort with computer use*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Tired Eyes*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Dry Eye Sensation*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Light Sensitivity*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Dizziness*
- 1 - Never
- 2 - Rarely
- 3 - Sometimes
- 4 - Very Often
- 5 - Always
Additional Notes
Any additional notes you'd like to add
Comments
This field is for validation purposes and should be left unchanged.

The Eye Site

1715 S. Wells Ave. Suite 100Meridian,Idaho83642

Phone(208) 898-0304Fax(208) 898-0380