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    DRY EYE RISK ASSESSMENT

Complete the Dry Eye Risk assessment and click on the "submit" button. We will contact you shortly about your results.

You may also print out the Dry Eye Risk Assement form and fax it into our office at (601) 352-5988 or bring it with you to your next appointment.

Name:
Date of Birth:
Email:

How often do you have these problems?
Redness Never Rarely Commonly Always
Sandy-gritty feeling Never Rarely Commonly Always
Itching Never Rarely Commonly Always
Excess watering Never Rarely Commonly Always
Burning Never Rarely Commonly Always
Excess mucous Never Rarely Commonly Always
Blurry vision helped by blinking Never Rarely Commonly Always
Blurry vision when reading Never Rarely Commonly Always

Are your eyes sensitive to these conditions?
Smoke Never Rarely Commonly Always
Light Never Rarely Commonly Always
Air pollution Never Rarely Commonly Always
Wind Never Rarely Commonly Always
Computer Screens Never Rarely Commonly Always
Heaters Never Rarely Commonly Always
Air Conditioners Never Rarely Commonly Always
Contact lenses Never Rarely Commonly Always

Have you been diagnosed with any of these conditions?
Thyroid abnormality Yes No
Rheumatoid arthritis Yes No
Asthma Yes No
Diabetes Yes No
Glaucoma Yes No
Lupus Yes No
Rosacea Yes No

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