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 NotesAny additional notes you'd like to addEmailThis field is for validation purposes and should be left unchanged.
