Dry Eye Questionnaire

Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we would ask that you take a few moments and thoughtfully complete the questionnaire below.
* Denotes required field.
Report the Frequency and Severity of your symptoms using the rating list below:
Dryness, Grittiness or Scratchines
Frequency:
Severity:
Soreness or Irritation
Frequency:
Severity:
Burning or Watering
Frequency:
Severity:
Eye Fatigue
Frequency:
Severity:
When was the last time you experienced these symptoms?
Do you use drops and/or ointment?
Do Dry Eye issues currently negatively impact your daily lifestyle?
Have you been told you have blepharitis or been treated for a stye?
What Dry Eye symptom bothers you the most?
Submit My Information Disclaimer: This survey does not replace an in-office exam, nor is it designed to provide online consultation. The information is intended for information purposes only and will help guide you to appropriate vision correction treatment(s) among the various procedures we offer today. It is not a determination for candidacy which can only be made through a thorough in-office examination and consultation.

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* Indica el campo obligatorio. Este formulario no confirma la fecha / hora de la cita. Nombramientos según disponibilidad.

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