Do You Suffer From Dry Eyes?

Name*

First Last

Phone*

Email*

About Dry Eye Disease

Dry Eye Disease is one of the most frequent reasons that patients visit eye doctors. To help us understand your condition better, explain to us how often you experience the symptoms below.

Eye Dryness, Grittiness, or Scratchiness

Never
Sometimes
Often
Constant

Soreness or Irritation

Never
Sometimes
Often
Constant

Burning or Watering

Never
Sometimes
Often
Constant

Eye Fatigue

Never
Sometimes
Often
Constant

Now please tell is the severity of your symptoms.
Tolerable – not perfect but not uncomfortable
Uncomfortable – irritating but does not interfere with my day
Bothersome – irritating and interferes with my day
Intolerable – unable to perform my daily tasksl

Eye Dryness, Grittiness, or Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue

Please select when you last experienced symptoms.

Today
Within Past 72 Hours
Within Past 3 Months

Do you use eye drops and/or ointment?

Yes
No

If yes, which drops or ointment do you use?

Have you ever been told that you have blepharitis or been treated for a stye?

No
Yes - Blepharitis
Yes - Stye
Yes - Both

hCaptcha*

Font Resizer

About Dry Eye Disease

Dry Eye Disease is one of the most frequent reasons that patients visit eye doctors. To help us understand your condition better, explain to us how often you experience the symptoms below.

Schedule A Consultation Today!

Schedule A Consultation Today! 254.772.4499