Dry Eye Questionnaire

Dry Eye Questionnaire

Please fill out the form below, and we will contact you within 1 business day to schedule you in for an appointment.
Name

First NameLast Name
Age
Phone Number

Area CodePhone Number
Email
example@example.com
Occupation
Please list eye surgeries (LASIK, PRK, cataract)
Please list current eye drops and current dry eye treatments
Please list unsuccessful dry eye treatments
Please list specialized diet (vegan, vegetarian, keto etc)

Report the effect of dry eye on your quality of vision and life

	1	2	3	4	5

1 is Mild, 5 is Severe

Report the SEVERITY of your symptoms using the rating list below:

	Never	Sometimes	Often	Constant
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Sensitivity to light
Blurry vision/Fluctuating vision

Please select if the following applies

SmokerAntihistaminesAnti-depressantsAuto-immune disorderRosaceaHistory of Accutane
Please select the treatment(s) that you would like to discuss:

Intense Pulse LightZest (Blepharitis) TreatmentLow-Level Light Therapy (Meibomian Gland Dysfunction)Pharmaceutical Eye DropsOver the counter / At-home remediesOther
Thank you for your submission. We look forward to taking care of your dry eyes and we will contact you within 1 business day.
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