Symptoms Checklist

The following fields are required

Name:
E-Mail:
Phone:

Check eye symptoms you experience:
  Left Right
Redness
Dry eye feeling
Mucous discharge
Sandy or gritty feeling
Itching
Burning
Foreign body sensation
Constant tearing
Occasional tearing
Watery eyes
Light sensitivity
Eye pain or soreness
Chronic infection of eye or lids
Sties, Chalazion
Fluctuating visual acuity
"Tired" eyes
Contact lens discomfort
Contact lens solution sensitivity

Check any of the following symptoms that you are having:

Sinus congestion
Congestion
Post-nasal drip
Cough-chronic
Bronchitis-chronic
Allergy symptoms
Seasonal allergies
Hay fever symptoms
Cold symptoms
Middle ear congestion
Sneezing
Dry throat, mouth
Headaches
Asthma symptoms
Arthritis
Joint pain
   
Additional comments:
 
Check all that apply:
 
Yes
    
Do you use lubricating eye drops?
What brand?
Do you wear contact lenses?
How long have you had them?
Are they comfortable?
Have you tried contacts before and quit?
Do you wear glasses?
How long have you had them?
Have you had an eye injury?
Describe:
Have you ever had eye surgery?
Describe:
Are you allergic to anything?
List:
Do you take any medications?
List:
 

 

 

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