Name*Email* Do your eyes feel uncomfortable when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo you have headaches when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo you lose concentration when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo you see the words move, jump, swim or appear to float on the page when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo your eyes ever hurt when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo your eyes ever feel sore when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo you notice the words blurring or coming in and out of focus when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysDo you lose your place when reading or doing close work?NeverVery Often/InfrequentlySometimesFairly OftenAlwaysPhoneThis field is for validation purposes and should be left unchanged.
