Dry Eye Evaluation Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? Yes No Do you have any of the following symptoms? Blurred Vision Eye Redness Watery Eyes Stringy Discharge Light Sensitivity Foreign Body Sensation Scratchy feeling of sand or grit in the eye Eye Fatigue Contact Lens Discomfort Have you had: Cataract Surgery Glaucoma Surgery Refractive Surgery Do you use: Contact Lenses Over the Counter Eye Drops, such as Artificial Tears Prescription Eye Drops for Dry Eye Syndrome (e.g. Restasis) Prescription Eye Drops for Glaucoma Prescription Eye Drops for Allergies Nutritional Supplements for Dry Eye (e.g. omega-3, flaxseed oil) Are your symptoms related to the following environmental conditions? Windy Conditions Places with low humidity (airplanes or hospitals) Areas that are air condition/heated Do you sleep with a ceiling fan? Yes No Are you taking any of the following medicines? Antihistamines / Decongestants Antidepressant or Anti-Anxiety Hormone Replacement Therapy or Estrogen Oral Corticosteriods Blood Pressure Medication Accutane (or other medication for acne) Questions/Comments? Would you like to receive News and Special Offers? Full Name: * Best email to send results to: *
