Dry Eyes Questionnaire

Brian K. Anderson, O.D.

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Dry Eyes Questionnaire

* Indicates required field

Name *

First

Last

Do you ever have problems with any of the following:

Eyes feel: (select all that apply) *

Dry Burning Too watery Itchy Like vision fluctuates while reading, on the computer, or driving Sensitive to lights Gritty or like you have sand in your eyes Uncomfortable after wearing contact lenses more than a few hours Tired when reading or on the computer Uncomfortable being in air conditioned / windy environments

On a scale of 1 - 5 (5 being the worst), how would you rate your dry eye symptoms? *

1 2 3 4 5

In the past, have you ever tried any dry eye treatments? *

Yes No

If yes, please provide the following information:

Name of your treatment: *

How often you use the treatment: *

[object Object]

Did the treatment help? *

Yes No

Dry eye discomfort is a very common problem. Fortunately, there are many differnet treatment options available to help you regain comfortable vision. Would you like to receive more information about ways to improve your dry eye symptoms? *

Yes No

Submit

Contact Us
3200 Soaring Gulls Drive
#104
Las Vegas, NV 89129
Phone: 702-645-3211

Office Hours
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Tue 8:00 am - 5:00 pm
Wed 8:00 am - 5:00 pm
Thu 8:00 am - 5:00 pm
Fri Closed

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Home
Our Practice
- New office remodel
Our Services
For Our Patients
Resources
Location