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Lifestyle Index Quiz

Name
MM slash DD slash YYYY

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? Fill in applicable circle.
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 )
mcculley optix gallery

Our Location

567 32nd Ave E.
West Fargo, ND 58078, USA

Contact Info

Phone: 701.373.2020

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