Visit Our Look Optometry Website
(323)-651-5646
Call Us
Book an Appointment
(323)-651-5646
Call Us
Book Appointment

NEUROLENSES QUESTIONNAIRE

Book an Appointment
FREE MYOPIA CONSULT

Lifestyle Index

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.
Book an Appointment

Neurolenses Questionnaire

How often do you experience any of these symptoms? Choose the applicable option.

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.
Headaches(Required)

Stiffness / Pain In Neck / Shoulders

  • You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).
Stiffness / Pain In Neck / Shoulders(Required)

Discomfort With Computer Use

  • You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).
Discomfort With Computer Use(Required)

Tired Eyes

  • Your eyes feel increasingly fatigued/tired as the day goes on.
Tired Eyes(Required)

Dry Eye Sensation

  • Your eyes progressively feel more dry/sandy/gritty while working at the computer or read.
Dry Eye Sensation(Required)

Light Sensitivity

  • Bright / Strong lights (vehicle headlights, florescent lights etc.) bother you.
Light Sensitivity(Required)

Dizziness

  • You experience dizziness, motion sickness, or vertigo.
Dizziness(Required)

Additional Notes

  • Any additional notes you'd like to add:

Fill out your information below to receive your results: