iTEAR100 Prescription Questionnaire

Fill out this form to request prescription from a company Doctor. Most of information is not required but like any Doctor visit, the more you provide, the easier it is for the company to determine if you will benefit from iTEAR treatment. If you are not comfortable submitting name and email then write in your initials and send us an email or fax with rest of information. You can also print this entire form and FAX to 206-984-1564 and/or send to itear100prescription@oo-med.com.

INTERNATIONAL PATIENTS MAY NOT NEED A PRESCRIPTION IN THEIR COUNTRY; HOWEVER WE APPLY SAME PROCESS AS IN THE U.S. AND A COMPANY DOCTOR WILL REVIEW THIS QUESTIONNAIRE PRIOR TO ALLOWING A PURCHASE. THIS PROCESS WILL ALLOW THE COMPANY TO SET EXPECTATIONS AND RECOMMENDATIONS AS FAR AS WHO WE THINK WILL BENEFIT MOST BASED ON OUR EXPERIENCE. INTERNATIONAL PATIENTS ALSO BENEFIT FROM HAVING A COMPANY DOCTOR IN THS U.S. TO ASSESS THEIR PROGRESS AND TRAIN IF NEEDED.

**PRESCRIPTION IS NOT GUARANTEED FOR FILLING OUT THIS INFORMATION

Date Submitted

Date

Name

First NameLast Name

Email*

example@example.com

Why are you filling out this form

Country*

State (If United States)

How long have you had problems with your eyes which may be diagnosed as dry eye (enter number for years)?

Please answer the following

	YES	No
1. Have you been diagnosed with dry eye?
2. Do you wear contact lenses?
3. Have you had LASIK surgery or other procedures on your eyes?
4. Do you wear eye makeup?
5. Do you have increased intraocular pressure or glaucoma?
6. Do you see an eyecare specialist with dry eye expertise?
7. Do you take medications known to cause dry eye such as anti-histamines, anti-depressants, anti-hypertensive, etc.?
8. Do you have a history of headaches or migraine?
9. Do you have a history or blepharitis (eyelid inflammation)
10. Do you have a history of trigeminal or herpetic neuralgia

If you answered yes to question 3, how long since your surgery

If you answered yes to question 5, how many medications do you require to control your intraocular pressure and what are the names

If you answered yes to question 8, do you require regular medication to control your headaches and/or migraines? do these headaches and/or migraines interfere with your daily life? How many headaches and/or migraines do you experience per month

What is your worst dry eye symptom

Age

Ethnicity (optional)

Biologic Gender (at birth)

MF

How many hours do you spend in front of the computer each day

Does computer usage make your symptoms worse?

YesNo

Have you tried or currently using any of the following (answer all that apply for each option)

	Yes Tried	Never Tried	Still Use
iTEAR100
True Tear (intranasal neurostimulation)
Oxervate
Tyrvaya
Restasis
Xiidra
IPL
Lipiflow
Meibomian Gland Expression (with IPL or alone)
Tearcare
Cequa
Nulids
Bruder Mask
VEYE
Regener-eyes
Klarity-C
Serum tears (From your own blood)
Over the counter artificial tears

If currently use artificial tears, how many times per day

List your current treatment regimen for symptoms if not indicated above? (include prescription and over the counter medications, vitamins, devices, etc)

Have you had a schirmer test

YesNoOther

If yes, what was score (if don't remember number and only remember Doctor comment [e.g. low, normal], then write in comment)

Have you had any meibomian gland testing and if yes, do you remember results

SPEED SURVEY

FREQUENCY of the following symptoms

	0-Never	1-Sometimes	2-Often	3-Constant
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Total score of Frequency (add rows)

SEVERITY of symptoms

	0-No Problem	1- Tolerable, not perfect but not uncomfortable	2-Uncomfortable, irritating but does not interfere with my day	3-Bothersome, irritating & interferes with my day	4 - Intolerable, unable to preform my daily tasks
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Total Severity Score (add Rows)

Total SPEED Score (add severity and frequency)

Any Other Medical History or Medications Which Might Cause your Symptoms

What insurance do you have? (not required)

How did you hear about iTEAR100?

Technical Ability (1-4) iTEAR100 requires an app for activation and other functions. We offer ability to bypass the app but only recommend this option for patients who cannot use phone applications*

4 Use apps on a daily basis3 Occasionally use apps2 Struggle with apps and avoid when possible1 Do not have a smart phone

Signature*