Dry Eye Evaluation
Select Office
Centennial Commons
Oak Court
Wolfcreek
First Name
Phone
(
)
-
Last Name
Email
How Often do you have ...?
Never
Sometimes
Frequently
Always
Score
Redness
Sandy or Gritty Sensation
Itching
Excess Watering
Burning
Excess Mucous
Blurred Vision
Are your eyes sensitive to ...?
Never
Sometimes
Frequently
Always
Score
Smoke
Light
Air Pollution
Wind
Heaters
Air Conditioning
Contact Lenses
How often do you use ...?
Never
Sometimes
Frequently
Always
Score
Anti-Depressants
Redness Reducing Eye Drops
Decongestants
Antihistamines
Blood Pressure Medication
Artificial Tear Drops
Hormones
Oral Contraceptives
Diuretics
Ulcer Medication
Tranquilizers
Beta Blockers
Incontinence Therapies
A
verage daily computer time
0 Hrs
1-2 Hrs
2-4 Hrs
Over 4 Hrs
Score
Hours
Have you ever been diagnosed with…?
Yes
No
Score
Thyroid Abnormalities
Rheumatoid Arthritis
Asthma
Diabetes
Glaucoma
Are you…?
Yes
No
Score
Over 45
Post-menopausal
Considering refractive surgery
Do you…?
Yes
No
Score
Experience Contact Lens discomfort
Get eyestrain
Blink your eyes excessively
As an Adult…?
Yes
No
Score
Have you had blemishes on your face?
If your scored 30 or higher you may have dry eyes. Please call our office for an evaluation
Total