Neurolens Speed Questionnaire The 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. PT Initials / IDDate MM slash DD slash YYYY Headaches(Required)of any severity each week, usually getting worse later in the day.1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysStiffness / pain in neck / shoulders(Required)when you work at a computer or read.1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysDiscomfort with Computer Use(Required)in your eyes (redness, burning) after long hours looking at the screen1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysDiscomfort with Computer Use(Required)in your eyes (redness, burning) after long hours looking at the screen1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysTired Eyes(Required)with increasing feeling of eye fatigue throughout the day.1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysDry Eye Sensation(Required)feeling progressively more gritty/sandy while working at computer or reading1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysLight Sensitivity(Required)especially with brighter, stronger light like flourescents or headlights1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysDizziness(Required)or an experience like motion sickness or vertigo1. Never2. Rarely3. Sometimes4. Very Often5. Always Δ
