Questionnaire
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
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