Complete Your Questionnaire in 5 minutes or less


What symptoms are you currently experiencing?

(Click all that apply)

Headaches
Headaches
Eye Strain
Eye Strain
Dizziness
Dizziness
Neck Pain
Neck Pain
Light Sensitivity
Light Sensitivity

What is the severity of these symptoms?

Low

Medium

High

What measures are you currently taking to manage your symptoms?

(Mark all that apply)

Pain Medicine (Ibuprofen, etc.)
Botox Injections
Chiropractor
Massage Therapy
Turning Off Lights
None


Other

Take an object and hold it 12 inches from your face

Close your left eye, then your right eye

​​

Object appear to move?

What is your name?


What is your email address?

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