MYZE

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MYZE

so now tell us what your eyes are feeling

1
What’s your first name?We’ll use this to personalize your experience.
2
1. Do your EYES FEEL IRRITATED, ITCHY OR GRITTY, like there’s something in there?
Never
Sometimes
Half of the time
All of the time
3
2. Do your EYES FEEL LIKE THEY’RE BURNING, ACHY OR SORE?
Never
Sometimes
Half of the time
All of the time
4
3. Are your EYES WATERY OR TEARY?
Never
Sometimes
Half of the time
All of the time
5
4. Do your EYES FEEL TIRED OR FATIGUED?
Never
Sometimes
Half of the time
All of the time
6
5. Do you have BLURRED VISION, even with glasses or contacts on?
Never
Sometimes
Half of the time
All of the time
7
6. Are your EYES RED AND IRRITATED?
Never
Sometimes
Half of the time
All of the time
8
7. When do your eyes feel and look their worst?
Morning (when you wake up)
Evening (at the end of your day)
Always
9
8. Do your symptoms get in the way of…(select all that apply)
Enjoying a sunny or breezy day
Reading a good book
Using my computer for work or fun
Watching my favorite TV shows
Using my mobile device
Driving at night
None of the above
10
So we can share your personalized daily routine with you, please let us know your email address?By inputting my email, I consent to receive communications from MYZE via email. I can always unsubscribe at any time. For further information, please review the MYZE Privacy Policy.
email@example.com
11
Now let's understand what may be causing your symptoms
12
8. How many hours per day are you watching your TV, looking at your phone, computer and/or tablet?
2-4 hours
4-7 hours
7-10 hours
10+ hours
13
9. Do any of the following apply to you? (Select all that apply)(Select all that apply)
No
Use a CPAP machine at night
Sleep with a fan on
Sleep with eyes open or partially open
14
11. Do you smoke?
YESNO
15
10. Do you FEEL YOUR EYES more when wearing contact lenses?
I don’t wear contact lenses
Never
Sometimes
Half of the time
All of the time
16
11. Would you characterize yourself as a competitive gamer?
Yes
No
17
A few more details will help us personalize your care plan
18
12. Have you had or will you have LASIK, PRK, ocular surgery or a cosmetic procedure near or around your eyes?(Select all that apply)
No
LASIK
PRK
Ocular Surgery
A cosmetic procedure
19
13. Do you have any of the following medical conditions?(Select all that apply)
Allergies
Depression or Anxiety
Sleep Apnea
Fibromyalgia
Diabetes
Migraines
Sjogrens Syndrome
Ocular Rosacea
Other Autoimmune Disease
Skin Issues around Your Eyes
Inflammatory Disease
None
20
13. Have you ever been treated for or diagnosed with Dry Eye Disease or other ocular disease or disorder?(Select all that apply)
Advanced Dry Eye Disease
Meibomian Gland Dysfunction (MGD)
Blepharitis
Floppy Eyelid Syndrome (FES)
Lagophthalmos
None
21
14. What products / treatments have you used or taken for your dry eye?(Select all that apply)
Prescription drugs
LipiFlow
Ocular hygiene products
iLux
Artificial tears
Radio Frequency Treatment (RF)
Intense Pulse Light (IPL)
22
15. Do you currently see any of the following health care professionals?(Select all that apply)
Primary care physician
Optometrist
Ophthalmologist
Dermatologist
Plastic Surgeon
23
Your personalized routine is ready! Your eyes will thank you!
24
20. What is your first and last name?
First Name
Last Name
25
21. Which of the following age groups do you fall into?
18-34 years old
35-54 years old
55+
26
22. What is your gender?
Female
Male
Non-binary
Would rather not say
27
23. We want to stay connected. What is your preferred method of contact?
Email
Text
28
24. How did you hear about us?
Instagram
You Tube
Tik Tok
Facebook
Friend/Family
Eye Care Professional
29
SCORING
30
For Q9 and Q13
31
Q7, Q9, Q13
Should be Empty:

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