Dry Eye Questionnaire
Dry Eye Evaluation
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          
 Average 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