Ocular Health Questionnaire Call Us Today calendar Schedule Appointment Name First Last Date MM slash DD slash YYYY PhoneEmail Ocular Comfort & Health Dry Eyes Blurry Vision Itching Gritty / scratchy Excessive tearing / watering eyes Foreign body sensation Stringy mucous in / around eyes Recurrent Styes Crusty / flaky eyelashes Fluctuating Vision Redness Burning Eye strain Tired Eyes Please check all symptoms experienced since the last visitHow often do you use artificial tears throughout the day? 0-2 2-4 5+ Can you wear your contacts comfortable as long as you would like? Yes No How many hours are you on the computer? 0-4 4-8 8+ Do your eyes feel drier at the beginning or the end of the day? Morning Night Constant Overall Health Allergies (Seasonal, medication, environment, etc) Hormonal Fluctuations Autoimmune disease (i.e. lupus, rheumatoid arthritis, rosacea, Sjrogen's) Low Water Intake Check any of the surgeries that you have had: LASIK PRK SMILE Cataract Blepharoplasty (Upper or Lower) List Current Medications: Add RemoveCheck any of the treatments that you have tried in the past: Artificial Tears Omega-3 Night Ointment Heat Mask Avenova Spray Punctal Plugs Restasis Cequa Xiidra Serum Tears Regener-eyes BlephEx LipiFlow Radiofrequency E-EYE IRPL Ocular Aesthetics Puffy skin under eyes Wrinkles around your eyes Dark circles / bags under the eyes Dark spots / Texture Face flushes easily (spicy food, hot shower, alcohol Crows feet near corners of your eyes Sensitivity to make-up around eyes Thinning lashes Please check all symptoms experiencedCAPTCHA Δ
