Dry Eye Questionnaire
Are you a good candidate for Dry Eye Treatment? Fill out the form below & we will be in contact with you shortly! If you are experiencing an eye emergency, please call our office at: (770) 499-2020.
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Please Report The Severity Of These Symptoms: Dryness, Grittiness Or Scratchiness
Never
Mild
Moderate
Severe
Please Report The Severity Of These Symptoms: Soreness Or Irritation
Never
Mild
Moderate
Severe
Please Report The Severity Of These Symptoms: Burning Or Watering
Never
Mild
Moderate
Severe
Please Report The Severity Of These Symptoms: Eye Fatigue
Never
Mild
Moderate
Severe
Please Check When You Last Experienced The Above Symptoms:
Today
Within The Last 3 Days
Within The Past 3 Months
Do you use eye drops for lubrication? If so, how often & what brand?
Do you have fluctuating vision (corrected with blinking)?
Never
Sometimes
Frequently
Always
Have you been told you have Blepharitis?
Please Select
Yes
No
I Don't Know
Have You Been Treated For A Stye
Please Select
Yes
No
I Don't Know
Please Check Any Symptoms You Have Experienced Recently:
Eyelid Redness
Crusting Around Lashes
Lid Irritation
Eye Itchiness
Other
Submit
Should be Empty: