Dry Eye Self Evaluation


Select Your age Group:




Please Select the Symptoms You are Experiencing:

Dryness, grittiness or scratchiness
Soreness or irritation
Burning
Eye Fatigue
Eye Pain
Watering
Excess mucous
Blurry vision helped by blinking often
Light sensitivity
Inflammation
Redness
None of the above
Other:




How often do you experience these symptoms?





How severe are your symptoms?





Have you had previous eye surgery?

Yes
No




What do you use to control your symptoms?

Over-the-counter eye drops
Medicated eye drops
Artificial tears
Wearing glasses instead of contacts
Restasis
Punctal plugs
Nothing
Other:




Select the conditions that irritate your eyes:


Contact Lenses
Smoke
Light
Wind/Fans
Computer Screens
Heaters or Air Conditioning
Dust
None of the above
Other:




Select the conditions you have been diagnosed with:


Asthma
Diabetes
Glaucoma
Lupus
Thyroid abnormality
Rosacea
Menopause or post-menopause
Rheumatoid Arthritis
Sjogren's Syndrome
None of the above