dry eye syndrome

EagleVison - Solutions for Better Vision

 


EagleVision Homepage
About EagleVision, Inc.
Practice Resource Center
Professional Education
EagleVision News
Our Products
Frequently Asked Questions
Resource Links
Patient Resources
Contact Us

Patient's Resources

Dry Eye Syndrome Questionaire
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

Please fill out this questionnaire, print and take to your next doctor's visit to assist your eye care professional in evaluating your symptoms.

top of page

 What is Dry Eye Syndrome? || Who is at Risk? || FAQ's
Diagnosis & Treatment || Dry Eye-Q Test || Testimonials

Home || About Us || Contact Us || News || EagleVision Disclaimer
 Practice Resources || Professional Education || Product Development
Products || FAQ's || Resource Links ||
Patient Resources


© 2002 Eagle Vision, Inc. All Rights Reserved.
E-mail: info@eaglevis.com - Customer Service: 1-800-222-7584
Website by Shasta Marketing Consultants