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What symptoms are you currently experiencing? (check all that apply)
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Headaches
Eye Strain
Neck Pain
Motion Sickness
Dry Eye
What is the severity of your head aches?
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2
3
4
5
What is the severity of your eye strain?
1
2
3
4
5
What is the severity of your neck pain?
1
2
3
4
5
What is the severity of your motion sickness?
1
2
3
4
5
What is the severity of your dry eye?
1
2
3
4
5
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2 of 4
What measures are you currently taking to manage your symptoms? (check all that apply)
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Medicine
Botox
Massage
Chiropractor
Other
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3 of 4
Take an object and hold it 12 inches from your face...
Close your left eye, then your right eye...
Repeat a few times
Did the object appear to move?
*
Yes
No
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Provide your info for a professional recommendation.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
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