Skip to main content
847-383-5852
Dry Eye Shop
Schedule Today
Open Menu
Close Menu
Home »

des

Ocular Health & Aesthetics Questionnaire

Name
MM slash DD slash YYYY
Ocular Comfort & Health
Please check all symptoms experienced since the last visit
How often do you use artificial tears throughout the day?
Can you wear your contacts comfortable as long as you would like?
How many hours are you on the computer?
Do your eyes feel drier at the beginning or the end of the day?
Overall Health
Check any of the surgeries that you have had:
List Current Medications:
Check any of the treatments that you have tried in the past:
Ocular Aesthetics
Please check all symptoms experienced