LIGHTING QUESTIONAIRE

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: Print this form blank - Do NOT complete it on the screen

The purpose of this questionnaire is for you to Print the blank questionaire 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.

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:   Very Low 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.

ATTITUDE On a scale of 1 to 10, rate your attitude: Very Negative Low Moderate High Very Positive     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 eye strain due to glare: Very Low 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: Very Low 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.