Dry Eyes – Optic Exclusive

Full Name

Email Address

Contact Number

General Questions

When is your symptoms worst?

Morning on awakening

Mid Mornings

Afternoon

Late Afternoon/at Night before bed

What medication are you using for your eyes?

If you are using HIV medication, or any other medication that you feel embarrassed about, please do NOT mention it on the questionnaire

What Medication are you using for your body?

Are you suffering from

Allergies

Arthritis

Thyroid Dysfunction

Any other systemic disease?

Are you suffering from

Dry Mouth

Dry Nose

Painful Joints

Do you have bags around your eyes?

Are you struggling to close your eyes?

Do you sleep with your eyes slightly open?

Are you suffering from work, family or emotional stress?

Have you experienced any of the following during the last week?

1. Eyes that are sensitive to light?

5. Poor vision?

2. Eyes that feel gritty?

3. Painful or sore eyes?

4. Blurred vision?

Have problems with your eyes limited you in performing any of the following during the last week?

6. Reading?

7. Driving at night?

8. Working with a computer or other electronic devices?

9. Watching TV?

Have your eyes felt uncomfortable in any of the following situations during the last week?

10. Windy conditions?

11. Areas that are air conditioned?

12. Places that are very dry (low humidity)?

Are you suffering of chronic gastritis or any other stomach ailment?

How stressed are you?

1: No Stress | 10: Very Stressed

Do you want to fill in the stress test?: CLICK HERE

Submit form to

Dry Eye Questionnaire

General Questions

Have you experienced any of the following during the last week?

Have problems with your eyes limited you in performing any of the following during the last week?

Have your eyes felt uncomfortable in any of the following situations during the last week?

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