Dry Eye Symptoms Checklist
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1
2DRY EYE SYMPTOMS CHECKLIST
Patient Name____________________________
Date_____________
Indicate symptoms or conditions you now experience, or have experienced duing the last 12 months.
Right
Left
Eye
Eye
EYE SYMPTOMS
SECONDARY SYMPTOMS
YES
YES
YES Sinus Problems
Sleep Apnea
Redness
Snoring
Dry Eye Feeling
Sneezing
Sandy or Gritty Feeling
Chronic Bronchitis
Itching
Allergy Symptoms
Burning
GERD
Foreign Body Sensation
Chronic Cold Symptoms
Constant Tearing
Middle Ear Congestion
Occasional Tearing
Heartburn or Indigestion
Watery Eyes
Dry Mouth or Throat
Light Sensitivity
Headaches
Eye Pain or Soreness
Asthma Symptoms
Sties, chalazion
Fluctuating Visual Acuity
"Tired" Eyes
List any non prescription medications, vitamins, or supplements
Contact Lens Discomfort
you take:
Contact Lens Solution Sensitivity
Mucous Discharge
Circle the items which you are sensitive to:
______How many glasses of water do you drink per day?
Pets
Air conditioning
_____ How many caffeinated drinks per day?
Heaters
Blowers/Fans
Sunshine
Contact Lens Wear
_____ How many hours do you use a computer per day?
Smog
Airplane Cabins
Dust
Computer Screens
Wind
Cigarette Smoke
YES
Do you use lubricating drops?
What brand?__________________________________
Do you wear contact lenses?
How often?___________________________________
Are your contact comfortable?
How many hours/day do you wear them?_________
How many years have you worn contacts?_________
Have you tried contacts before and quit?
Why?___________________________
______________________________________________
Do you wear glasses?
How many years have you worn glasses?___________
Have you ever had eye surgery or an injury? Describe :___________________________
Patient's Signature_________________________________________
DRY EYE SYMPTOMS CHECKLIST
Patient Name____________________________
Date_____________
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Parent category: Life