Eye Wellness Assessment Questionnaire Form
Please complete this self-assessment to help evaluate your current eye wellness. All questions are non-sensitive and designed for personal wellness insight.
How often do you experience eye strain during the day?
*
Never
Rarely
Sometimes
Often
Always
Rate your overall vision clarity.
*
1
2
3
4
5
Do you wear corrective lenses (glasses or contact lenses)?
*
Yes, glasses
Yes, contact lenses
No
How many hours per day do you spend looking at screens (computer, phone, TV)?
*
Please Select
Less than 2 hours
2-4 hours
5-7 hours
8 or more hours
How frequently do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Dry eyes
1
2
3
4
Itchy or burning sensation
5
6
7
8
Blurred vision
9
10
11
12
Headaches
13
14
15
16
Sensitivity to light
17
18
19
20
Do you take regular breaks from screen time (every 20-30 minutes)?
*
Yes
No
Sometimes
How would you rate your eye comfort at the end of a typical day?
*
Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
Do you use any eye drops or artificial tears?
*
Yes, daily
Yes, occasionally
No
Have you noticed any recent changes in your vision?
*
No changes
Slight changes
Significant changes
Please share any additional comments or concerns about your eye wellness.
Submit
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