Dry Eye Questionnaire

Print, fill out, and bring to your appointment if you wish to speed things up.

Name:__________________________________________ Date:___/___/_____

Problem: For How Long?:

Eyes feel dry? ....................................................................................................Right / Left / Both

Dry mouth and throat ?  .........................................................................................................Yes/No

Discharge from the eyes? ................................................................................Right / Left / Both

Feels like something in your eye? ...................................................................Right / Left / Both

Sandy gritty feeling? .......................................................................................Right / Left / Both

Itching and burning? .........................................................................................Right / Left / Both

Redness? ..............................................................................................................Right / Left / Both

Tearing or Watering? .......................................................................................Right / Left / Both

Sinus or nasal trouble/congestion? ................................................................Right / Left / Both

Light sensitivity? ................................................................................................Right / Left / Both

Eye pain or soreness? ........................................................................................Right / Left / Both

Chronic infections of eyes, lids or styes? .....................................................Right / Left / Both

Systemic Lupus? (or relatives) .............................................................................................Yes/No

Sjorens Syndrome? (or relatives) ........................................................................................Yes/No

Sarcoidosis? (or relatives) ....................................................................................................Yes/No

Bells Palsy? (or relatives) ......................................................................................................Yes/No

Have you ever been treated for a dry eye condition? .....................................................Yes/No

Do you take any eye drops? type? .......................................................................................Yes/No

Contact lens discomfort?  .......................................................................................................Yes/No

Contact lens solution sensitivity?  .........................................................................................Yes/No

How many times during your sleep do you get up to urinate?_______

Does your eye dryness increase during certain seasons? (which?) ................................Yes/No

Heaters Yes/No Blowers Yes/No Air conditioning Yes/No Smoke Yes/No Smog Yes/No

Monitors Yes/No Pollen Yes/No Pressured planes Yes/No Wind Yes/No Dust Yes/No

Water: __oz X __  Diet Pop: __oz X __  Coffee: __oz X __  Wine: __oz X __

Juice: __oz X __  Pollen: __oz X __ Tea: __oz X __  Beer: __oz X __

Are you taking medication?......................................................................................................Yes/No