Please fill out this questionnaire, print and take to your next doctor's visit to assist your eye care professional in evaluating your symptoms. Please check the appropriate response: Redness never rarely commonly always Sandy-gritty feeling never rarely commonly always Itching never rarely commonly always Excess watering never rarely commonly always Burning never rarely commonly always Excess mucous never rarely commonly always Blurry Vision helped by blinking never rarely commonly always Smoke never rarely commonly always Light never rarely commonly always Air Pollution never rarely commonly always Wind never rarely commonly always Computer Screens never rarely commonly always Heaters never rarely commonly always Air Conditioning never rarely commonly always Contact Lenses never rarely commonly always Anti-Depressants never rarely commonly always Redness Reducing Eye Drops never rarely commonly always Decongestants never rarely commonly always Antihistamines never rarely commonly always Blood Pressure Medicine never rarely commonly always Artificial Tears never rarely commonly always Hormones never rarely commonly always Oral Contraceptives never rarely commonly always Diuretics never rarely commonly always Ulcer Medication never rarely commonly always Tranquilizers never rarely commonly always Beta Blockers never rarely commonly always Thyroid Abnormality No Yes Rheumatoid Arthritis No Yes Asthma No Yes Diabetes No Yes Glaucoma? No Yes Lupus No Yes Are you over 50? No Yes Do you experience contact lens discomfort? No Yes Are you post menopausal? No Yes Do you get eye strain ? No Yes Do you blink your eyes excessively? No Yes Are you considering refractive surgery? No Yes
Please check the appropriate response:
Redness never rarely commonly always
Sandy-gritty feeling never rarely commonly always
Itching never rarely commonly always
Excess watering never rarely commonly always
Burning never rarely commonly always
Excess mucous never rarely commonly always
Blurry Vision helped by blinking never rarely commonly always
Smoke never rarely commonly always
Light never rarely commonly always
Air Pollution never rarely commonly always
Wind never rarely commonly always
Computer Screens never rarely commonly always
Heaters never rarely commonly always
Air Conditioning never rarely commonly always
Contact Lenses never rarely commonly always
Anti-Depressants never rarely commonly always
Redness Reducing Eye Drops never rarely commonly always
Decongestants never rarely commonly always
Antihistamines never rarely commonly always
Blood Pressure Medicine never rarely commonly always
Artificial Tears never rarely commonly always
Hormones never rarely commonly always
Oral Contraceptives never rarely commonly always
Diuretics never rarely commonly always
Ulcer Medication never rarely commonly always
Tranquilizers never rarely commonly always
Beta Blockers never rarely commonly always
Thyroid Abnormality No Yes
Rheumatoid Arthritis No Yes
Asthma No Yes
Diabetes No Yes
Glaucoma? No Yes
Lupus No Yes
Are you over 50? No Yes
Do you experience contact lens discomfort? No Yes
Are you post menopausal? No Yes
Do you get eye strain ? No Yes
Do you blink your eyes excessively? No Yes
Are you considering refractive surgery? No Yes