Lifestyle Questionnaire

At the Georgia Eye Center, we strive to provide you with the best possible eye care experience. To understand your unique needs, we request that new patients complete a lifestyle questionnaire prior to their appointment. This allows our team to gain valuable insights into your daily habits, activities, and overall lifestyle, enabling us to tailor our services to suit you. Thank you for choosing The Georgia Eye Center, where your visual wellness matters.

Fields marked with an asterisk (*) are required.

This survey is meant to help your doctor understand what you’re experiencing on a regular basis and asses the possible effects work and leisure activities may have on your eye health. Your responses ensure that you receive the best eye care possible.

Lifestyle Questionnaire

Which of the following visual demands do you encounter on a regular basis? *

Which of the following hobbies or activities do you participate in? *

Do your eyes seem bothered by glare from any of the following situations? *

If you wear contacts, do you have ____? *

Are you having any concerns with your current glasses or contacts? *

Are you interested in getting information about LASIK? *

Do you experience headaches of any severity each week? Do these headaches tend to get worse later in the day or are they worse at work than at home or on the weekends?

Do you experience neck stiffness or soreness when you work on a computer or read, experience frequent tension in your head, neck, or shoulders, get frequent massages or visit the chiropractor often?

Do you experience discomfort with computer use? Do you feel that you are more productive in the morning vs. the afternoon? Do your eyes get tired, burn, or get red easily when you work at a computer for long hours?

Are your eyes tired or fatigued at the end of a work day or do they generally feel better in the morning compared to the end of the day?

do your eyes or contacts tend to dry out when you're working at a computer or reading or feel progressively dryer as the day goes on?

Do you find night driving difficult due to glare form headlights? Do fluorescent lights bother you in large spaces such as grocery or department stores?

Does riding in a car give you motion sickness or do you sometimes feel a sensation of vertigo or disconnectedness from your environment?

7 + 2 =

Contact Details

If you have questions about this questionnaire or your upcoming appointment with Dr. Jones please do not hesitate to reach out to us.


4135 Lavista Rd Ste 100 Tucker, GA 30084

The Georgia Eye Center is conveniently located on Lavista Road In tucker, Georgia in the Northlake Square plaza. We are very convenient to I-285 and there is plenty of available parking.

Dr. Kyle Jones

Georgia Eye Center