Light Sensitivity Questionnaire
Name
*
Age
*
Email
*
example@example.com
When was your last eye exam?
*
Do you live in Vancouver?
*
Yes
No
Do you have any of the following (check all that apply):
*
History of concussion / motor vehicle accident
Neurological Disorder
Migraine
Migraine with visual aura
Stiffness/pain in neck and/or shoulders
Blepharospasm
Headaches (more than 2x per week)
Dry Eye Sensation
How often do you experience the following symptoms upon exposure to bright or artificial light:
*
Rows
Never
Sometimes
Often
Always
Headache
Dizziness or Vertigo
Eyestrain
Light intolerance
Anxiety
How often are the above selected symptoms worsened by
*
Rows
Never
Sometimes
Often
Always
Fluorescent Lights
Car Headlights
Sunlight Exposure
Digital Screen Lighting
How long have you been suffering with the above mentioned symptoms?
Less than 1 month
1-6 months
6-12 months
12+ months
Does your light sensitivity affect your quality of life?
*
Never
Rarely
Sometimes
Often
Always
On average, how many hours a day do you spend in front of digital screens?
*
0 - 2
3 - 5
6 - 8
9 - 11
12 +
On average, how many hours a day are you under fluorescent/LED lighting?
*
0 - 2
3 - 5
6 - 8
9 - 11
12 +
How often do you wear eyeglasses?
*
Never
Sometimes
Always
Would you like more information regarding:
FL-41 tint
Blue light filter
BluTech Filter
Polarized outdoor tint
Indoor tint
Special tinted contact lenses
Dry Eye treatment
Submit
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