Please review and fill out this form prior to your Computer Eyestrain Evaluation
Work Practices:
1. Number of hours per workday of VDT viewing:
2. How long have you worked at a job requiring this amount of VDT use?
3. Type of work habits: (circle one)
Intermittent (periods of less than 1 hour)
Constant (informal breaks, as required)
Constant (no breaks, other than meals)
Intermittent (periods of more than 1 hour)
Environment (check all that apply)
Lighting in the work area
Fluorescent overhead only
Flourescent and Incandescent overhead
Incandescent overhead only
Window light in front of you
Fluorescent overhead and incandescent direct
Window light behind you
Right Side
Left Side
Window light control:
Curtains?
Blinds? Vertical or Horizontal
Desk Lamp/Task Light
Other: (describe)
Walls: What color?
Shiny
Dull finish
Desk surfaces: What color?
Shiny
Dull finish
How would you rate the brightness of the room?
Very
Medium
Dim
Display Screen:
What color are the letters on your screen?
What color is the background of your screen?
Viewing distance from your eye to VDT screen (be sure you have someone else measure this while you sit in front of the monitor, otherwise you may lean in too close)
Can the monitor be tilted?
Yes
No
Can the monitor be Raised or lowered?
Yes
No
Do you notice the screen flicker?
Yes
No
If so, is it
Glass
Mesh
Top of VDT screen
above eye level
at eye level
below eye level
If above or below, by how many inches?
Workstation
Viewing distance from your eye to keyboard:
inches
Viewing distance from your eye to hard copy material:
inches
Reference material is to the side; below
If to the side, is it next to the screen or next to the keyboard
Is this height adjustable?
Yes
No
Is the monitor supported on a
stand
desk
CPU
Is this adjustable?
Yes
No
Is all of your hard copy material visible without significant movements?
Yes
No
Visual Symptoms
Do you experience any of the following symptoms during or after VDT work?
Eyestrain
Backaches
Headaches
Light Sensitivity
Blurred Near Vision
Color Distortion
Blurred Distant Vision
Neck, Shoulder or Wrist Aches
Dry/Irritated Eyes
Double Vision
Do you wear glasses while working at the VDT?
Yes
No
If yes, are your lenses
single vision (distance only)
Bifocal (with a line)
no-line or progressive lenses
Do you wear contact lenses while worknig at the VDT?
Yes
No
If yes, are they soft or rigid gas permeable lenses
VDT COMPREHENSIVE EXAMINATION
Evaluation
Cover Test:
Vergences: Exo deviation = Sheardís Criterion = Base Out(positive) = 2X the amount of exophoria
Eso deviation = Percivalís Criterion = Patient should be operating in middle 1/3 of vergence range.
Distance Lateral Phoria: (prescribe prism at near if Eso)
NRA: (+)
(taken at patientís VDT distance; less than +/- 1.50 abnormal; donít overprescribe)
PRA: (-)
(taken at patientís VDT distance; less than +/- 1.50 ablnormal; donít overprescribe)
Amplitude:
(+/- 1.50 lens with 10 cycles per minute adequate)
Prio Subjective: OD
(Alternate test is Dynamic Retinoscopy with 20/60 letters)
Prio Subjective: OS
(Alternate test is Dynamic Retinoscopy with 20/60 letters)
Eye Health:
Tear Film Stability (TBUT) seconds:
Blink Rate (1 every ___ seconds)
Lids:
Aposition:
Good
Poor
Can the monitor be Raised or lowered?
Yes
No
Bulbar Conj:
clear
injected
dry reflection
Room illumination: 3X brighter than VDT brightness if pupils are large PUPIL SIZE:
