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OKO Health - Nutritional Ophthalmology Questionnaire

We appreciate your interest in eye health! Nutritional Ophthalmology is here to help you. Please fill out this questionnaire to assist you better, and our team will contact you within 24 hours. 

Please note that all your information will remain confidential between you and OKO Health. Click the link below to see our privacy policy.
1.Personal information
2.What services are you interested in?
3.Do you have or are you worried about any of these medical conditions?
4.Tell me about your eyes. What is the problem?
5.How often do you have eye symptoms? 

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
6.How often do you have cravings for sugary or fatty foods such as sweets, chocolates, bread, cakes and chips?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
7.Are you eating snacks (chips, chocolate, or anything else as snack)

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
8.Do you experience an afternoon energy slump?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
9.Are you eating fried food (fries, chicken tenders, hamburgers, fast food)?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
10.Do you suffer from Headaches?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
11.Do you have insomnia or difficulty sleeping?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
12.Do you suffer from constipation? 

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
13.Do you suffer from bloating?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
14.Do you experience diarrhea:

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
15.Do you experience joint pain?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
16.Do you experience fatigue or low energy?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
17.Do you experience mood swings?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
18.Do you experience stress, anxiety, or depression?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
19.Do you struggle with focus and concentration that impacts your performance?

(0 = Never / 1 = Occasionally & Not Severe / 2 = Occasionally & Severe / 3 = Frequently & Not Severe / 4 = Frequently & Severe).
20.Are you committed to changing your lifestyle to improve your skin?
21.Do you have diabetes?
22.Do you love your skin?
23.How often do you exercise? 

(0 = None / 1 = Once per Week / 2 = Twice per Week / 3 = Three times per Week / 4 = Daily).
24.Please describe what exercise you most typically do? 
25.DO you need to lose weight or gain weight?