1. How often do you have redness?
   Never Sometimes
   Frequently Always
2. How often do you have sandy or gritty sensation?
   Never Sometimes
   Frequently Always
3. How often do you have itching?
   Never Sometimes
   Frequently Always
4. How often do you have excess watering?
   Never Sometimes
   Frequently Always
5. How often do you have burning?
   Never Sometimes
   Frequently Always
6. How often do you have excess mucous?
   Never Sometimes
   Frequently Always
7. How often do you have blurred vision?
   Never Sometimes
   Frequently Always
8. Are your eyes sensitive to smoke?
   Never Sometimes
   Frequently Always
9. Are your eyes sensitive to light?
   Never Sometimes
   Frequently Always
10. Are your eyes sensitive to air pollution?
    Never Sometimes
    Frequently Always
11. Are your eyes sensitive to wind?
    Never Sometimes
    Frequently Always
12. Are your eyes sensitive to heaters?
    Never Sometimes
    Frequently Always
13. Are your eyes sensitive to air conditioning?
    Never Sometimes
    Frequently Always
14. Are your eyes sensitive to contact lenses?
    Never Sometimes
    Frequently Always
15. How often do you use anti depressants?
    Never Sometimes
    Frequently Always
16. How often do you use redness reducing eye drops?
    Never Sometimes
    Frequently Always
17. How often do you use decongestants?
    Never Sometimes
    Frequently Always
18. How often do you use antihistamines?
    Never Sometimes
    Frequently Always
19. How often do you use blood pressure medication?
    Never Sometimes
    Frequently Always
20. How often do you use artificial tear drops?
    Never Sometimes
    Frequently Always
21. How often do you use hormones?
    Never Sometimes
    Frequently Always
22. How often do you use oral contraceptives?
    Never Sometimes
    Frequently Always
23. How often do you use diuretics?
    Never Sometimes
    Frequently Always
24. How often do you use ulcer medication?
    Never Sometimes
    Frequently Always
25. How often do you use tranquilizers?
    Never Sometimes
    Frequently Always
26. How often do you use beta blockers?
    Never Sometimes
    Frequently Always
27. How often do you use incontinence therapies?
    Never Sometimes
    Frequently Always
28. Average daily computer time hours ?
    0 Hrs 1-2 Hrs
    2-4 Hrs Over 4 Hrs
29. Have you ever been diagnosed with thyroid abnormalities?
    Yes No
30. Have you ever been diagnosed with rheumatoid arthritis?
    Yes No
31. Have you ever been diagnosed with asthma?
    Yes No
32. Have you ever been diagnosed with diabetes?
    Yes No
33. Have you ever been diagnosed with glaucoma?
    Yes No
34. Are you over 45?
    Yes No
35. Are you post-menopausal?
    Yes No
36. Are you considering refractive surgery?
    Yes No
37. Do you experience contact lens discomfort?
    Yes No
38. Do you get eyestrain?
    Yes No
39. Do you blink your eyes excessively?
    Yes No
40. As an adult, have you had blemishes on your face?
    Yes No

*If your scored 30 or higher you may have dry eyes. Please call our office for an evaluation