Lighting Questionnaire

If you would like to research how your current lighting is affecting you and others, use the  following form. If you purchase the full spectrum lighting, you can check its positive effects by using the form also.

Note: You can complete this form on screen four times: 9 A.M., 12 P.M., 3 P.M. , and 5 P.M. however you will need to leave the screen open. At 5 p.m. print it out so you will have a record of your responses. If you must close the screen out – print it, otherwise any responses you have made will NOT be saved.

The purpose of this questionnaire is for you to Print the blank questionnaire and fill one copy daily to track for a week or two how you feel under the cool white fluorescent tubes. After changing to the full spectrum tubes you can refill the form each day for a week or two to really see the difference.

Name:

Date:

Headaches:
Do you have a headache?
  YES NO     YES NO
9 A.M. 12 P.M.
3 P.M. 5 P.M.

Fatigue:
On a scale of 1 to 10, rate your level of fatigue:
  No fatigue Low Moderate High Very High
  1 2 3 4 5 6 7 8 9 10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

Productivity:
On a scale of 1 to 10, rate your level of productivity:
  No fatigue Low Moderate High Very High
  1 2 3 4 5 6 7 8 9 10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

Glare:
On a scale of 1 to 10, rate your level of glare:
  No fatigue Low Moderate High Very High
  1 2 3 4 5 6 7 8 9 10
9 A.M.
12 P.M.
3 P.M.
5 P.M.

Anxiety:
On a scale of 1 to 10, rate your level of anxiety:
  No fatigue Low Moderate High Very High
  1 2 3 4 5 6 7 8 9 10
9 A.M.
12 P.M.
3 P.M.
5 P.M.