La Paz Optometric Center
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Mission Viejo Optometric Center
Brookhurst Optometric Center

Could Neurolens™ Be Right for You?

Headaches, tired eyes, light sensitivity, dizziness, and neck or shoulder discomfort may sometimes be associated with eye misalignment and visual strain. Rate how often you experience each symptom to help our team better understand your concerns.

This questionnaire is informational and does not provide a diagnosis. A professional evaluation is required to determine whether Neurolens™ may be appropriate for you.

RATING INSTRUCTIONS

Thinking about a typical week, rate each statement from 1 to 5:

1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Very Often

"*" indicates required fields

SYMPTOM QUESTIONS

1. I experience headaches that become more noticeable after reading, using digital devices, or completing visually demanding tasks.
2. I experience stiffness, tension, or discomfort in my neck or shoulders while reading or working at a computer.
3. My eyes feel uncomfortable, irritated, or strained after extended screen use.
4. My eyes feel increasingly tired or fatigued as the day progresses.
5. My eyes feel dry, gritty, or sandy while reading, working at a computer, or using a digital device.
6. I experience sensitivity or discomfort around bright lights, fluorescent lighting, or oncoming headlights.
7. I experience dizziness, motion sickness, or a sensation that my surroundings are moving.

Let’s Discuss Your Results

Share your information below, and a member of our team will contact you to discuss your symptoms and possible next steps.

FORM DISCLAIMER

By submitting this form, you agree that a member of our Optometric Center team may contact you by phone or email regarding your responses and appointment options.

This questionnaire is for informational purposes only and is not a medical diagnosis or confirmation of Neurolens™ candidacy. An eye care professional must complete an evaluation to determine whether Neurolens™ is appropriate for your needs. This form is not monitored for urgent eye concerns.