Patient Name(Required)Date(Required) DD slash MM slash YYYY 1. Reading and Near Work Words blur or move on the page Letters or lines double up or disappear I lose my place when reading I need to re-read text to understand it I read more easily with colored paper or background 2. Pattern Sensitivity Stripes, checks, or repetitive patterns cause discomfort Strong contrasts (e.g. black text on bright white paper) are uncomfortable Geometric patterns (grids, escalators, blinds) make me dizzy or tired 3. Light Sensitivity I am sensitive to bright sunlight Fluorescent or LED lights bother me Glare from screens, paper, or shiny surfaces cause strain Symptoms change depending on time of day or lighting conditions 4. Headaches and Eye Discomfort I get headaches after reading or screen use I feel pressure or strain around the eyes Headaches are worse in bright light 5. Screen Use I struggle with computer or phone use I notice text blurs or shimmers when scrolling I need to adjust screen brightness or color to cope 6. Daily Impact I avoid reading or limit the amount I read Night driving or glare is difficult My work or study is affected Sunglasses or colored filters sometimes make me more comfortable 7. Family Link A family member has similar symptoms I have tried tinted glasses and noticed a difference 8. Dry Eyes I suffer from dry eyes Dry eye drops do not help me much Additional commentsCAPTCHA Δ
