Dry Eye Survey

Name(Required)
All of the timeMost of the timeHalfSome of the timeNone
Eyes that are sensitive to light?
Eyes that feel gritty?
Painful or sore eyes?
Blurred vision?
Poor Vision?
All of the timeMost of the timeHalfSome of the timeNone
Reading
Driving at night?
Working with a computer or bank machine (ATM)
Watching TV?
All of the timeMost of the timeHalfSome of the timeNone
Watching TV?
Places or areas with low humidity (i.e. very dry)
Areas that are air conditioned?
YesNo
Antihistamines (oral or eye drops)
Diuretics (water pill for hypertension)
Sleeping Pills
Hormone Replace Therapy
Oral Contraceptives
Tranquilizers
Beta-Blockers
Anti-depressants
Chemotherapy