Dry Eye Test
This questionnaire will be used by the doctor to help determine if you are an ideal candidate for "MYTEARS." Please answer the following questions to the best of your knowledge.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. Have you experienced any of these symptoms in the past 3 months or longer?
*
Rows
YES OR NO
Dryness. Grittiness or Scratchiness
YES
NO
Soreness or Irritation
YES
NO
Burning or Watering
YES
NO
Eye Fatigue
YES
NO
2. Do you depend on artificial tears to alleviate these symptoms?
*
Please Select
YES
NO
3. Have you used products like Restatis or Cequa in the past?
*
Please Select
YES
NO
4. What are your therapy goals?
5. Do you suffer from Sjorgen's Syndrome?
*
Please Select
YES
NO
6. Have you ever tested positive for the following?
*
Rows
YES OR NO
Hepatitis B
YES
NO
Hepatitis C
YES
NO
HIV / AIDS
YES
NO
Syphilis
YES
NO
7. If unsure, are you able to obtain bloodwork for the following conditions?
*
Please Select
YES
NO
8. Overall, how would you rate your eyes comfort level from a scale of 1 to 5? A score of 1 being no/ minimal discomfort and a score of 5 being extremely uncomfortable.
*
1 Minimal Dryness / NO discomfort
2 Mild Dryness/ Slight discomfort
3 Moderate Dryness / Moderate discomfort
4 Severe Dryness / Discomfort
5 Extreme Dryness / Painfull
Math Challenge
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