Header (727)-346-8696
Font Size   Decrease  Reset  Increase 

Dry Eye Self Evaluation Test

  1. (required)
  2. (required)
  3. (valid email required)
  4. (required)
  5. Sex
  6. Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.

  7. Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below:
    0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant
  8. Symptoms
  9. Dryness, Grittiness or Scratchiness
  10. Soreness or Irritation
  11. Burning or Watering
  12. Eye Fatigue

  13. Report the SEVERITY of your symptoms using the ratings list below:
  14. 0 = No problems
    1 = Tolerable - not perfect but not uncomfortable
    2 = Uncomfortable - irritating but does not interfere with my day
    3 = Bothersome - irritating and interferes with my day
    4 = Intolerable - unable to perform my daily tasks
  15. Symptoms
  16. Dryness, Grittiness or Scratchiness
  17. Soreness or Irritation
  18. Burning or Watering
  19. Eye Fatigue
  20. Please check if you have experienced symptoms:
Eye Drops/Ointment
  1. Do you use eye drops and/or ointment?
Treated for:
  1. Have you been told that you have blepharitis or have you been treated for a stye?
  2. Blepharitis
  3. Stye
Fluctuating Vision Problems
  1. Do you have fluctuating vision problems? (That can be corrected with blinking)
 

cforms contact form by delicious:days

Driving Directions

Our doctors proudly offer LASIK surgery and other eye care services to those traveling from nearby communities. For your convenience, we have provided driving directions from the following cities: