Neurolens Questionnaire

Lifestyle Index

Please fill out the questionnaire below or you may download the form and bring into the office on your next visit.

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, usually getting worse later in the day.

Stiffness / pain in neck / shoulders

  • When you work at acomputer or read.
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Discomfort with Computer Use

  • In your eyes (redness, burning) after long hours looking at the screen.
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Tired Eyes

  • With increasing feeling of eye fatigue throughout the day.
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Dry Eye Sensation

  • Feeling progressively more gritty/sandy while working at a computer or reading.
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Light Sensitivty

  • Especially with brighter, stronger lights like fluorescents or headlights.
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Dizziness

  • Or an experience like motion sickness or vertigo.
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Additional Notes

Any additional notes you'd like to add:

admin none 9:00 am - 5:00 pm 9:00 am - 6:00 pm 9:00 am - 1:00 pm 9:00 am - 6:00 pm 10:00 am - 5:00 pm 8:00 am - 2:00 pm Closed # # # https://www.google.com/maps/place/Jewel+City+Optometry/@34.1589976,-118.2404469,17z/data=!4m12!1m2!2m1!1shttps:%2F%2Fwww.google.com%2Fsearch%3Fq%3Djewel%2Bcity%2Boptometry%26source%3Dhp%26ei%3D7Pl7YnhGbKyqtsPn6KW4AM%26iflsig%3DAJiK0e8AAAAAY3wH_OvuvIIfDUjELUYMtrgm5QBh0JMt%26ved%3D0ahUKEwjph5_S+p8D7AhUymWoFHRRBTwQ4dUDCAs%26uact%3D5%26oq%3Djewel%2Bcity%2Boptometry%26gs_lcp%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%26sclient%3Dgwswiz%23lrd%3D0x80c2c1a5847007f7:0x10120a4d783cd210,3,,,!3m8!1s0x80c2c1a5847007f7:0x10120a4d783cd210!8m2!3d34.1589217!4d-118.2404244!9m1!1b1!15sCs8GaHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS9zZWFyY2g_cT1qZXdlbCtjaXR5K29wdG9tZXRyeSZzb3VyY2U9aHAmZWk9N1BsN1luaEdiS3lxdHNQbjZLVzRBTSZpZmxzaWc9QUppSzBlOEFBQUFBWTN3SF9PdnV2SUlmRFVqRUxVWU10cmdtNVFCaDBKTXQmdmVkPTBhaFVLRXdqcGg1X1MgcDhEN0FoVXltV29GSFJSQlR3UTRkVURDQXMmdWFjdD01Jm9xPWpld2VsK2NpdHkrb3B0b21ldHJ5JmdzX2xjcD1DZ2RuZDNNdGQybDZFQU15Q3dndUVJQUVFTWNCRUs4Qk1nVUkgQUJDR0F6SUZDQUFRaGdNeUJRZ0FFSVlETWdVSUFCQ0dBeklGQ0FBUWhnTTZDQWd1RUlNQkVMRURPZ3NJTGhDQUJCQ3hBeERVQWpvUkNDNFFnIEFRUXNRTVFnd0VReHdFUTBRTTZDQWd1RUxFREVJTUJPZ3NJTGhDQUJCREhBUkRSQXpvT0NDNFFnQVFRc1FNUWd3RVExQUk2Q3dnQUVJQSBFRUxFREVJTUJPZ3NJTGhDQUJCQ3hBeENEQVRvTENDNFExQUlRc1FNUWdBUTZDQWd1RUlBRUVMRURPZzRJTGhDQUJCQ3hBeERIQVJEUkF6b0YgQ0FBUWdBUTZDQWdBRUlBRUVNa0RPZ2dJQUJDQUJCQ3hBem9JQ0FBUXNRTVFnd0U2QndnQUVJQUVFQW82Q2dnQUVJQUVFTEVERUFvNkNnZ0EgRUlBRUVNa0RFQW82RFFndUVJQUVFTWNCRUs4QkVBbzZDQWd1RUxFREVJQUVPZzRJTGhDdkFSREhBUkN4QXhDQUJEb0ZDQUFRc1FNNkJRZ3VFIElBRU9oRUlMaENBQkJDeEF4REhBUkN2QVJEVUFqb0xDQzRRcndFUXh3RVFnQVE2QmdnQUVCWVFIam9JQ0FBUUZoQWVFQTlRQUZqaUhXRFNIMmcgQmNBQjRBSUFCcXdHSUFkd1BrZ0VFTVRZdU5aZ0JBS0FCQVEmc2NsaWVudD1nd3N3aXojbHJkPTB4ODBjMmMxYTU4NDcwMDdmNzoweDEwMTIwYTRkNzgzY2QyMTAsMywsLCIDiAEBkgELb3B0b21ldHJpc3TgAQA!16s%2Fg%2F1thgbqpk