Dry Eye Self Test Name* First Last Phone*Email* How often do you have redness?NeverSometimesFrequentlyAlwaysHow often do you have sandy or gritty sensation?NeverSometimesFrequentlyAlwaysHow often do you have itching?NeverSometimesFrequentlyAlwaysHow often do you have excess watering?NeverSometimesFrequentlyAlwaysHow often do you have burning?NeverSometimesFrequentlyAlwaysHow often do you have excess mucous?NeverSometimesFrequentlyAlwaysHow often do you have blurred vision?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to smoke?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to light?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to air pollution?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to wind?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to heaters?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to air conditioning?NeverSometimesFrequentlyAlwaysAre your eyes sensitive to contact lenses?NeverSometimesFrequentlyAlwaysHow often do you use anti depressants?NeverSometimesFrequentlyAlwaysHow often do you use redness reducing eye drops?NeverSometimesFrequentlyAlwaysHow often do you use decongestants?NeverSometimesFrequentlyAlwaysHow often do you use antihistamines?NeverSometimesFrequentlyAlwaysHow often do you use blood pressure medication?NeverSometimesFrequentlyAlwaysHow often do you use artificial tear drops?NeverSometimesFrequentlyAlwaysHow often do you use hormones?NeverSometimesFrequentlyAlwaysHow often do you use oral contraceptives?NeverSometimesFrequentlyAlwaysHow often do you use diuretics?NeverSometimesFrequentlyAlwaysHow often do you use ulcer medication?NeverSometimesFrequentlyAlwaysHow often do you use tranquilizers?NeverSometimesFrequentlyAlwaysHow often do you use beta blockers?NeverSometimesFrequentlyAlwaysHow often do you use incontinence therapies?NeverSometimesFrequentlyAlwaysAverage daily computer time hours ?0 Hrs1-2 Hrs2-4 Hrs4+ HrsHave you ever been diagnosed with thyroid abnormalities?YesNoHave you ever been diagnosed with rheumatoid arthritis?YesNoHave you ever been diagnosed with asthma?YesNoHave you ever been diagnosed with diabetes?YesNoHave you ever been diagnosed with glaucoma?YesNoAre you over 45?YesNoAre you post-menopausal?YesNoAre you considering refractive surgery?YesNoDo you experience contact lens discomfort?YesNoDo you get eyestrain?YesNoDo you blink your eyes excessively?YesNoAs an adult, have you had blemishes on your face?YesNoCAPTCHA Δ
