Dry Eye Evaluation Form

Please check if you have experienced the above symtoms.

Today

Within the past 3 days

Within the past 3 months

Do you use drops for lubrication?

Yes

No

Do you have fluctuating vision that improves when you blink?

Never‎

Sometimes‎

Frequently‎

Always‎

Have you been told you have Blepharitis?

Yes

No

Have you been treated for a Stye?

Yes

No

Have you had any of these symptoms recently?

Eyelid redness

Crusting around lashes

Lid irritation

None of the above

Dry Eye Clinic