Phone number

Email

age

How many hours do you spend on your digital screen?
< 1 h
1-2 h
2-3 h
3-4 h
4-6 h
> 6 h

How many hours you spend watching your screen in dark-room ?
< 1 h
1-2 h
2-3 h
3-4 h
4-6 h
> 6 h
Choice 7

The hours you spend on your digital screen are :
Continuous
Interrupted

To what level you illuminate your digital screen (brightness) in room light ?
< 10%
11%-25%
26%-50%
51%-75%
76%-100%

Are you spending most of the your screen time during the day or during the night ?
The day
The night

Do you have any of the following symptoms ?
Headaches
Fatigue
Dry eyes
Blurred vision
Eye strain
Double vision
Neck/shoulder/back pains
Eye redness and irritation
Difficulty refocusing the eyes

Do you have a previously diagnosed Dry Eye Diseas ?
Yes
No

Are you using any topical eye drops for this dry eye ?
Yes
No

Do you have any refractive errors ?
Yes
No
I don't know

Are you wearing glasses or contact lenses ? *
Yes
No

Describe the details of objects you see after prolonged hours on your digital screen :
Clearzy
Blurred
Hazy

After using my smart phone for prolonged hours, I am complaining of :
Joint pain in my fingers and wrists
Inability to hold objects well
Difficulty to write using the pen
Shoulders pain
None

How many years did you spent this way on the screen :
Nearly 1 year
Nearly 2 year
Nearly 3 year
Nearly 4 year
> 5 years

I am frequently using :
Touch Screen
Touch-pad
Note pen
Mouse and keyboard

Are you usually studying MEDICINE using :
Screens
Books
Both

Do you feel that the digital screen affects your life style and eye health ?
Yes
No

Are you willing to decrease your screen hours to guard against CVS ?
Yes
No