Dry Eye Questionnaire

Dry Eye Questionnaire
Full Name*

First NameLast Name
Date of Birth*
Contact Number*
Email Address
example@example.com
Health Insurance Card - Front:*

Please upload a photo of the front of your insurance card(s).
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Health Insurance Card - Back:*

Please upload a photo of the back of your insurance card(s).
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Dry eye is a complex condition caused by multiple factors affecting tear production and the ocular surface, not just a lack of tears. Without identifying the underlying cause, doctors and patients often resort to trial-and-error treatment. A comprehensive examination will be conducted to determine the true cause of symptoms and create a personalized treatment plan. While there is no cure for dry eye, committing to the treatment plan can lead to success in managing the condition.

Stay calm, trust the process, follow the plans, and you will be successful!

Your history is important in helping us better understand your condition, its potential causes, and how we can help you. Please answer the questions thoughtfully.

	Name	City	State
Primary Eye Care Doctor
Primary Care Physician
Rheumatologist
Who referred you to us?

Eye Conditions (check all that apply):*

CataractsGlaucomaMacular DegenerationDry Eye SyndromeRetinal Tear / DetachmentLazy EyeEye InjuryEye Surgery / LASIKOtherNone
If "Other," please explain:
Medical Conditions (check all that apply):*

DiabetesHypertensionThyroid dysfunctionHepatitis CHerpes (Simplex/Zoster)DepressionSjogren'sBell's PalsyAllergies/HypersensitivityRosacea/DermatitisSleep Disorder/CPAPAutoimmune DiseaseRheumatoid ArthritisLupus/FibromyalgiaSarcoidosisChemotherapy/RadiationPregnant/NursingOtherNone
If "Other," please explain:
Medications (check all that apply):*

DiureticAntihistamineDecongestantAccutaneBotox InjectionsAntidepressant / Anti-anxietyHormone ReplacementOral ContraceptivesFish Oil / Flaxseed OilAnti-inflammatoryAnti-hypertensive (statins)Analgesic (pain reliever)AntacidOtherNone
If "Other," please explain:
Do you have a family history of any of the following?

CataractsType I DiabetesGlaucomaType II DiabetesMacular DegenerationHypertensionRetinal Tear / DetachmentCancerLazy EyeHyperthyroidismOther eye diseaseHypothyroidismOther medical conditionNone
Please explain who in your family have any of the above conditions (father, sister, paternal grandfather, etc.):

	Symptoms
When you wake up in the middle of the night
When you wake up in the morning
Midday
In the evening

How do you spend your day (work, hobbies, etc.)?*
How many hours per day do you spend looking at screens or electronic devices (phone, computer, television, etc.)?*
How many OUNCES of water do you drink each day?*
What else do you drink each day?*
How many times a month do you eat fish?*
How many TOTAL hours of sleep do you get each night?*
How many hours of UNINTERRUPTED sleep do you get each night?*
Contact lens status:*

Current wearerPrevious wearerNever
Smoking status:*

Current smokerPrevious smokerNever
Please describe your home environment:*
Do you have depression?*
Do you have anxiety?*
Rank your current stress level:*
Rank your exercise / physical activity level:*
Is there anything else you would like us to know?
Should be Empty:

	Severity (0 is low, 10 is high)	Frequency	Which Eye is Worse?
Hard to open
Frequent blinking
Blink to see better
Tearing
Discharge
Gritty
Itching
Burning
Redness
Light sensitivity
Pain
Discomfort
Other

	Yes/No	Severity (1 is low, 10 is high)	How Long Have You Experienced This Symptom?
Dry mouth
Unexplained fatigue
Joint pain
Other