SYMPTOMS CHECKLIST
The following fields are
required
.
Name
Date
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: