NeuroLens Lifestyle Index

To understand your level of visual symptoms.

Name

Date

Directions

For each of the following questions, please select the number for the response which best represents how often you experience the listed symptoms. Please provide an answer for all 7 questions listed.

1. Headaches - during the week or worse at the end of the day

2. Stiffness / Pain in Neck / Shoulders - computer work or reading (posture?)

3. Discomfort with Computer use - eyes easily burn, get tired or red with use

4. Tired Eyes - increased fatigued / tiredness as the day goes on

5. Dry Eye Sensation - increasing dry, gritty eyes while on the computer or reading

6. Light Sensitivity - bright strong lights bother you e.g. indoor lights or car lights

7. Dizziness - frequency of dizziness, motion-sickness or vertigo

Consent *

Yes, I agree with the privacy policy and terms and conditions.

Signature

Start signing your signature here

Total of 1, 2 & 3 => 9 symptomatic=> 9 symptomatic

Total of 4, 5, 6 & 7 => 21 symptomatic=> 21 symptomatic

What Our Patients Are Saying About Us

What is your aspirational eye-brain connection in this digital age?

Excellence in NeuroVision

Oakville Centre for Vision provides friendly, professional services with excellence in eye care and quality products. Dr. Gall cares for you, your NeuroVision and your aspirational visually-fit outcomes.

Oakville Centre for Vision - Vision Therapy GTA Introduction

Vision Therapy and Eye Strain - Oakville Centre for Vision

Follow Us On Social Media

Facebook Youtube

Contact

506 Kerr Street, Oakville, ON L6K 3C5
(905) 338-2020
(905) 338-9192
PatientCare@OakvilleCentreForVision.com

Menu

Privacy Policy
Terms and Conditions
Site Map