Central Phoenix Eye Care-a VISION SOURCE! affiliate
Steven H. Kantor, O.D.
A. James Frank, III, O.D.
Heather L. Thompson, O.D.
5727 North 7th Street, Suite 105
Phoenix, Arizona 85014-5815
Phone: 602-265-8597 Fax: 602-265-6811
www.centralphoenixeyecare.com
Computer Vision Syndrome Questionnaire
If you are having difficulties while working on the computer, either at work or at home, please print this questionnaire and fill it out as best you can. There are now special lenses for those persons who use computers regularly that may help ease some of the symptoms you are experiencing. For the doctor to accurately assess your vision needs and possibly prescribe appropriate eyewear for computer use, complete the following information.
Number of hours per day spent at the computer:_____ Work is performed while: __Sitting __Other (please describe):_________________________
Describe the lighting in your work area: __fluorescent __incandescent __facing window
Other:_______________________________________________
Are you experiencing any of the following symptoms while at your computer (check appropriate areas)? __Headaches __Blurred near vision __Blurred distance vision __Slowness in focusing __Double vision __Sore or tired eyes (strain) __Glare (light) sensitivity __Dry or watery eyes __Burning, itching, or red eyes __Neck and shoulder pain __Back pain
Do you wear glasses while working at the computer? __No __Yes If yes, please bring them with you to the eye exam.
Do you wear contact lenses while working at the computer? __No __Yes If yes, please wear them to the eye exam.
Do you view reference materials while working at the computer? __No __Yes If yes, what percentage of the time? ___
In inches, what is the viewing distance from your eye to the computer screen? __ In inches, what is the viewing distance from your eye to the keyboard? __ In inches, what is the viewing distance from your eye to reference material? ____
Please check where appropriate. __The center of the screen is above eye level. __The center of the screen is equal to eye level. __The center of the screen is below eye level.
If above or below, by how many inches? __Reference material is above eye level. __Reference material is equal to eye level. __Reference material is below eye level.
If above or below, by how many inches? ___
