| |
| How Often do you have ...? |
|
Never |
|
Sometimes |
|
Frequently |
|
Always |
|
Score |
| |
Redness |
|
|
|
|
|
|
|
|
|
|
| |
Sandy or Gritty Sensation |
|
|
|
|
|
|
|
|
|
|
| |
Itching |
|
|
|
|
|
|
|
|
|
|
| |
Excess Watering |
|
|
|
|
|
|
|
|
|
|
| |
Burning |
|
|
|
|
|
|
|
|
|
|
| |
Excess Mucous |
|
|
|
|
|
|
|
|
|
|
| |
Blurred Vision |
|
|
|
|
|
|
|
|
|
|
| Are your eyes sensitive to ...? |
|
Never |
|
Sometimes |
|
Frequently |
|
Always |
|
Score |
| |
Smoke |
|
|
|
|
|
|
|
|
|
|
| |
Light |
|
|
|
|
|
|
|
|
|
|
| |
Air Pollution |
|
|
|
|
|
|
|
|
|
|
| |
Wind |
|
|
|
|
|
|
|
|
|
|
| |
Heaters |
|
|
|
|
|
|
|
|
|
|
| |
Air Conditioning |
|
|
|
|
|
|
|
|
|
|
| |
Contact Lenses |
|
|
|
|
|
|
|
|
|
|
| How often do
you use ...? |
|
Never |
|
Sometimes |
|
Frequently |
|
Always |
|
Score |
| |
Anti-Depressants |
|
|
|
|
|
|
|
|
|
|
| |
Redness Reducing Eye Drops |
|
|
|
|
|
|
|
|
|
|
| |
Decongestants |
|
|
|
|
|
|
|
|
|
|
| |
Antihistamines |
|
|
|
|
|
|
|
|
|
|
| |
Blood Pressure Medication |
|
|
|
|
|
|
|
|
|
|
| |
Artificial Tear Drops |
|
|
|
|
|
|
|
|
|
|
| |
Hormones |
|
|
|
|
|
|
|
|
|
|
| |
Oral Contraceptives |
|
|
|
|
|
|
|
|
|
|
| |
Diuretics |
|
|
|
|
|
|
|
|
|
|
| |
Ulcer Medication |
|
|
|
|
|
|
|
|
|
|
| |
Tranquilizers |
|
|
|
|
|
|
|
|
|
|
| |
Beta Blockers |
|
|
|
|
|
|
|
|
|
|
| |
Incontinence Therapies |
|
|
|
|
|
|
|
|
|
|
| Average daily
computer time |
|
0 Hrs |
|
1-2 Hrs |
|
2-4 Hrs |
|
Over 4 Hrs |
|
Score |
| |
Hours |
|
|
|
|
|
|
|
|
|
|
| Have you ever been diagnosed with…? |
|
|
|
Yes |
|
No |
|
|
|
Score |
| |
Thyroid Abnormalities |
|
|
|
|
|
|
|
|
|
|
| |
Rheumatoid Arthritis |
|
|
|
|
|
|
|
|
|
|
| |
Asthma |
|
|
|
|
|
|
|
|
|
|
| |
Diabetes |
|
|
|
|
|
|
|
|
|
|
| |
Glaucoma |
|
|
|
|
|
|
|
|
|
|
| Are you…? |
|
|
|
Yes |
|
No |
|
|
|
Score |
| |
Over 45 |
|
|
|
|
|
|
|
|
|
|
| |
Post-menopausal |
|
|
|
|
|
|
|
|
|
|
| |
Considering refractive surgery |
|
|
|
|
|
|
|
|
|
|
| Do you…? |
|
|
|
Yes |
|
No |
|
|
|
Score |
| |
Experience Contact Lens discomfort |
|
|
|
|
|
|
|
|
|
|
| |
Get eyestrain |
|
|
|
|
|
|
|
|
|
|
| |
Blink your eyes excessively |
|
|
|
|
|
|
|
|
|
|
| As an Adult…? |
|
|
|
Yes |
|
No |
|
|
|
Score |
| |
Have you had Blemishes on your face? |
|
|
|
|
|
|
|
|
|
|
If your scored 30 or higher you
may have dry eyes. Please call our office for an evaluation
 |
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| |
|