Dry Eye Medical Questionnaire

Dry Eye Medical Questionnaire

Answer the questions about your symptoms, history, and current medications to help prescreen you for care.
Full Name

First NameLast Name
Email Address
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Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Have you been previously diagnosed with dry eye disease?
How long have you been experiencing symptoms of dry eye?
Which symptoms are you currently experiencing? (Select all that apply)

Other
Are you currently using any eye drops or medications for your eyes?
Do you have any of the following conditions? (Select all that apply)
On average, how many hours per day do you spend looking at screens (computer, phone, TV)?
Please list any medications you are taking (including eye drops).
Your Location

Straße und Hausnummer

Straße und Hausnummer (zweite Zeile)

CityState

Zipcode
Should be Empty: