Please enter your contact details (required):

Your details will not be printed on the completion page but will be submitted to our clinic.

Your name:

Your phone:

Your email:

Do any of the following bother your eyes, head, and stomach; make you dizzy, tired, nervous, anxious or irritable?

Reading textbooks for extended periods?

Reading on a computer for extended periods?

Working or reading under fluorescent lights?

Reading black print on high gloss white paper?

Doing visually-intensive activities like needlepoint, cross stitching, woodworking, crossword puzzles?

Bothered by sunlight?

Bothered by glare outside; glare off chrome on cars?

Bothered by glare off high gloss white paper?

Bothered by glare on hazy days?

Bothered by bright lights?

Bothered by fluorescent lights?

Bothered by headlights from oncoming traffic?

Certain patterns or stripes bother you?

Bright or neon colors bother you?

Do you frequently wear sunglasses?

Do you become tired or drowsy under bright or fluorescent lighting?

Do you get a headache from fluorescent lighting?

Do you feel antsy or fidgety when under fluorescent lighting?

Does your performance deteriorate under bright or fluorescent lighting?

Do you feel like there is too much light when reading?

Do you feel like there is not enough light when reading?

Do you read in dim lighting?

Do you feel like you need less light to read?

Your response contain errors which are highlighted in red. Please correct them and try again.
Cancel

Share This