|
Dry Eye Survey
Please print out this survey and answer the following questions by circling the
most appropriate response.
1. a.) What is your age?
Under 25 years 25-45 years
over 45 years
b.) Are you male or
female? Male
Female
2. a.) Do you ever experience any of the
following eye symptoms? (circle those that apply to you).
Soreness Scratchiness
Dryness Grittiness
Burning
b.) How often do
you have these symptoms?
Never
Sometimes
Often
Constantly
3. Have you ever had drops prescribed or other treatment for
dry eyes?
Yes No
Uncertain
4. Do you suffer from arthritis?
Yes No
Uncertain
5. Do you suffer from any thyroid condition?
Yes No
Uncertain
6. Do you experience dryness of the nose, mouth, throat, chest, or vagina?
Never
Sometimes
Often
Constantly
7. Do you regard your eyes as being unusually sensitive to
cigarette smoke, smog, air conditioning, or central heating?
Yes No
Sometimes
8. Do your eyes easily become very red and irritated when
swimming in chlorinated fresh water?
Yes No
Sometimes Not
Applicable
9. Do you take any of the following (circle):
Antihistamine tablets or drops diuretics (fluid tablets)
sleeping tablets tranquilizers
oral contraceptives medications for digestive problems
decongestants blood pressure medications
10. Are you eyes dry and irritated the day after drinking
alcohol?
Yes No
Sometimes
11. Are you known to sleep with your eyes partially open?
Yes No
Sometimes
12. Are your eyes irritated when you wake up?
Yes No
Sometimes
Scoring System
Review your answers above and give the appropriate point value to the answers.
1.
Female over 45 years
6
Female 25-45 years
2
Male over 45 years
2
Male 25-45 years
0
Male or Female under 25 0
2. Experiencing one or more dry eye symptoms:
Constantly
8
Often
4
Sometimes
1
3. Previous prescription for dry eye treatment
Yes
6
4. Arthritis sufferer
2
5. Thyroid condition
2
6. Mucus membrane dryness
Constantly
2
Often
1
Sometimes
1
7. Unusual sensitivity
Yes
2
Sometimes
1
8. Irritation when swimming
Yes
2
Sometimes
1
9. Systemic medications reducing tear production
Yes
1
10. Irritation after drinking alcohol
Yes
2
Sometimes
1
11. Nocturnal lagophthalmos (sleep with eyes partially open)
Yes
2
Sometimes
1
12. Irritation upon awaking
Yes
2
Sometimes
1
Total your points and classify yourself with using the following table.
TOTAL _________
Score > 14 = dry eye syndrome
Score < 6 = normal
Score 7-13 = marginal dry eye if dry eye symptoms
If your score is above 6, then you may benefit from dry eye treatment. Make an
appointment so we can assess your problem and start your treatment.
|
