NeuroLens Lifestyle Index To understand your level of visual symptoms. NameDateDirectionsFor 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 daySelect1. Never2. Rarely3. Sometimes4. Very Often5. Always2. Stiffness / Pain in Neck / Shoulders - computer work or reading (posture?)Select1. Never2. Rarely3. Sometimes4. Very Often5. Always3. Discomfort with Computer use - eyes easily burn, get tired or red with useSelect1. Never2. Rarely3. Sometimes4. Very Often5. Always4. Tired Eyes - increased fatigued / tiredness as the day goes onSelect1. Never2. Rarely3. Sometimes4. Very Often5. Always5. Dry Eye Sensation - increasing dry, gritty eyes while on the computer or readingSelect1. Never2. Rarely3. Sometimes4. Very Often5. Always6. Light Sensitivity - bright strong lights bother you e.g. indoor lights or car lightsSelect1. Never2. Rarely3. Sometimes4. Very Often5. Always7. Dizziness - frequency of dizziness, motion-sickness or vertigoSelect1. Never2. Rarely3. Sometimes4. Very Often5. AlwaysConsent *Yes, I agree with the privacy policy and terms and conditions.SignatureStart signing your signature hereYour browser does not support e-Signature field.Total of 1, 2 & 3 => 9 symptomatic=> 9 symptomaticTotal of 4, 5, 6 & 7 => 21 symptomatic=> 21 symptomatic Send Message