Dry Eye Evaluation Questionnaire

Dry Eye Evaluation Questionnaire
You may Also Print & Fax (**Fax #: 954-491-7164**)
**Eye Care's Dry Eye Evaluation Questionnaire**

Personal Information

How Often do you have ...?

Redness
Score: 0
Sandy or Gritty Sensation
Score: 0
Itching
Score: 0
Excess Watering
Score: 0
Burning
Score: 0
Excess Mucous
Score: 0
Blurred Vision
Score: 0

Are your eyes sensitive to ...?

Smoke
Score: 0
Light
Score: 0
Air Pollution
Score: 0
Wind
Score: 0
Heaters
Score: 0
Air Conditioning
Score: 0
Contact Lenses
Score: 0

How often do you use ...?

Anti-Depressants
Score: 0
Redness Reducing Eye Drops
Score: 0
Decongestants
Score: 0
Antihistamines
Score: 0
Blood Pressure Medication
Score: 0
Artificial Tear Drops
Score: 0
Hormones
Score: 0
Oral Contraceptives
Score: 0
Diuretics
Score: 0
Ulcer Medication
Score: 0
Total Score: 0

Our Services

Testimonial

“I needed an eye exam and cheap glasses frames but I didnt like the last place I went in pompano. researched eye doctors in fort lauderdale and discount eyeglasses stores and found World Eyeglasses. Best discount eye glasses frames and cheap eye exams. Everyone there is nice and it was fast too.”
Brittnie Chavez

* The patient and any other person responsible for payment has a right to refuse to pay, cancel payment or be reimbursed for payment for any other service, examination or treatment which is performed as a result of and within 72 hours of responding to the advertisement for the free discounted fee or reduced fee service, examination or treatment.