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How Serious Is Your Dry Eye?
2 minutes. Personalized results. Find out what your symptoms are telling you.
14
Questions
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1
Having you experienced any of the following?
*
This field is required.
During a typical day of the last month.
Constantly
Mostly
Often
Sometimes
Never
Sensitivity to light
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Blurred vision
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Sensitivity to light
Blurred vision
Constantly
Row 0, Column 0
Mostly
Row 0, Column 1
Often
Row 0, Column 2
Sometimes
Row 0, Column 3
Never
Row 0, Column 4
Constantly
Row 1, Column 0
Mostly
Row 1, Column 1
Often
Row 1, Column 2
Sometimes
Row 1, Column 3
Never
Row 1, Column 4
1
of 2
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2
Have problems with your eyes limited you in any of the following?
*
This field is required.
During a typical day of the last month.
Constantly
Mostly
Often
Sometimes
Never
Driving or being driven or night?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Watching TV, or a similar task?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Driving or being driven or night?
Watching TV, or a similar task?
Constantly
Row 0, Column 0
Mostly
Row 0, Column 1
Often
Row 0, Column 2
Sometimes
Row 0, Column 3
Never
Row 0, Column 4
Constantly
Row 1, Column 0
Mostly
Row 1, Column 1
Often
Row 1, Column 2
Sometimes
Row 1, Column 3
Never
Row 1, Column 4
1
of 2
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3
Have your eyes felt uncomfortable in any of the following situations?
*
This field is required.
During a typical day of the last month.
Constantly
Mostly
Often
Sometimes
Never
Windy conditions?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Places or areas with low humidity?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Windy conditions?
Places or areas with low humidity?
Constantly
Row 0, Column 0
Mostly
Row 0, Column 1
Often
Row 0, Column 2
Sometimes
Row 0, Column 3
Never
Row 0, Column 4
Constantly
Row 1, Column 0
Mostly
Row 1, Column 1
Often
Row 1, Column 2
Sometimes
Row 1, Column 3
Never
Row 1, Column 4
1
of 2
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4
Total symptom score
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5
Score Tag
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6
Overall, how much do your eyes bother you on a daily basis?
Scale of 1-10
Scale of 1-10
Not at all
2
3
4
Moderately
6
7
8
9
Extremely & Constantly
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Scale of 1-10
Not at all
2
3
4
Moderately
6
7
8
9
Extremely & Constantly
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
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7
How long have you been dealing with these symptoms?
Less than 3 months
3–12 months
1–3 years
More than 3 years
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8
How often do you use artificial tears?
Rarely or never
Once or twice a day
3–4 times a day
More than 4 times a day
I use them constantly throughout the day
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9
*
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First Name
Last Name
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10
You've come this far — don't leave without your results.
*
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We'll email you a personalised summary based on your score, along with information about next steps. You can unsubscribe at any time.
Yes, email me my results and follow-up information from Dr. Madan. I can unsubscribe at any time.
No thank you, I'll skip my results.
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11
Email
*
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example@example.com
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12
What would you like to do with your results?
*
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I'd like to book a consultation with Dr. Madan
I'm not ready to book yet — send me my results and more information
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13
Best phone number to reach you
Area Code
Phone Number
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14
Which clinic is most convenient?
*
This field is required.
Vancouver — Kerrisdale Professional Building
North Vancouver — Lynn Valley Optometry
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15
Which treatments are you interested in learning about? (optional, select all that apply)
I'd like Dr. Madan's recommendation
Blepharitis Treatment
MYE Drop Personalized PRP Therapy
Intense Pulse Light Therapy (IPL)
Jett Plasma
Chalazion/Stye Treatment
Amniotic Membranes
Thermal Pulsation
Meibomian Gland Expression
Punctal Plugs
Medication for dry eyes
Radiofrequency
Scleral Lenses
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16
Anything else you'd like Dr. Madan to know?
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