Dry Eye Self-Evaluation

1

Select your age group

Under 18

19-39

40-59

60+

2

Please select the symptoms you are experiencing* This field is required.Select all that apply

Dryness, grittiness or scratchiness

Soreness or irritation

Burning

Eye fatigue

Eye pain

Watering

Excess mucus

Blurry vision helped by blinking often

Light sensitivity

Inflamation

Redness

None of the above

3

How often do you experience these symptoms* This field is required.

Never

Often

Sometimes

Always

4

How severe are your symptoms?* This field is required.

Tolerable

Uncomfortable

Bothersome

Intolerable

5

Have you had previous eye surgery?* This field is required.

YESNO

6

What do you use to control your symptoms?* This field is required.Select all that apply

Over-the-counter eye drops

Medicated eye drops

Artificial tears

Wearing glasses instead of contacts

Restasis

Punctal plugs

Nothing

Other

9

Can we get your name?* This field is required.

First Name

Last Name

10

Are you a current patient?

YESNO

11

What is your phone number?

Area Code

Phone Number

12

What is your email?* This field is required.

example@example.com