Lifestyle Index
This survey 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.
Email address *
Name *
Your answer
Date
MM
/
DD
/
YYYY
How often do you experience any of these symptoms?
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.
Your headaches are generally worse at work than they are at home or on weekends.
You get headaches of any severity each week (even just a dull ache counts).
Your headaches tend to get worse later in the day.
Your headaches are generally worse at work than they are at home or on weekends.
Never
Always
Stiffness or Pain in Neck or Shoulders
Your neck gets stiff and sore when you work at a computer or read (This might even be
from your posture).
You experience frequent tension in your head, neck or shoulders.
You get frequent massages/chiropractic adjustments.
Your neck gets stiff and sore when you work at a computer or read (This might even be
from your posture).
You experience frequent tension in your head, neck or shoulders.
You get frequent massages/chiropractic adjustments.
Never
Always
Discomfort with Computer Use
You feel like you are more productive at work in the morning vs. the afternoon.
Your eyes get tired, burn, or get red easily when you work at a computer for long hours.
You feel like you are more productive at work in the morning vs. the afternoon.
Your eyes get tired, burn, or get red easily when you work at a computer for long hours.
Never
Always
Number of hours per day using a digital device:
Your answer
Tired Eyes
Your eyes feel fatigued/tired at the end of a workday.
Your eyes generally feel better in the morning compared to the end of the day.
Your eyes feel fatigued/tired at the end of a workday.
Your eyes generally feel better in the morning compared to the end of the day.
Never
Always
Dry Eye Sensation
Captionless Image
Never
Always
Light Sensitivity
Driving at night is difficult because of glare from highlights.
Fluorescent lights bother you in large spaces (grocery store, department store, etc.).
Driving at night is difficult because of glare from highlights.
Fluorescent lights bother you in large spaces (grocery store, department store, etc.).
Never
Always
Dizziness
Riding in a car gives you motion sickness.
You sometimes feel a sensation of vertigo or disconnectedness from your environment.
Riding in a car gives you motion sickness.
You sometimes feel a sensation of vertigo or disconnectedness from your environment.
Never
Always
Additional Notes?
Your answer
Phone number
Your answer
Can we text you?
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