Download Dry Eye Questionnaire - Hudson Valley Eye Surgeons

Daniel C. Brocks, MD
DRY EYE QUESTIONNAIRE
PLEASE NOTE: THIS QUESTIONNAIRE IS FOR A DRY EYE EXAMINATION. THE EXAMINATION YOU ARE SCHEDULED FOR IS TO DIAGNOSE,
EVALUATE AND TREAT DRY EYES. IT IS NOT MEANT TO BE A SUBSTITUTE FOR ANY REGULARLY SCHEDULED COMPREHENSIVE EYE EXAMS.
PLEASE COMPLETE AND SIGN THIS QUESTIONNAIRE AND RETURN THE ENTIRE PACKET TO OUR OFFICE AT LEAST ONE WEEK PRIOR TO YOUR
EXAM.
PLEASE DO NOT TAKE ANY EYE DROPS FOR ONE HOUR PRIOR TO YOUR EXAM
PLEASE BRING ALL CURRENT MEDICATIONS, EYE DROPS AND SUPPLEMENTS WITH YOU TO THE EXAM.
I HAVE READ AND UNDERSTAND THE ABOVE INSTRUCTIONS FOR MY DRY EYE EXAM.
__________________________________ ____________
PATIENT SIGNATURE
© 2013 HUDSON VALLEY EYE SURGEONS, PC
DATE
NAME: _____________________________________
DOB: ________________________
GENDER
DATE:_________________
AGE: ___________
 MALE
 FEMALE
ARE YOU CURRENTLY PREGNANT OR NURSING?
 YES
CURRENT PHYSICIANS:
PRIMARY MEDICAL DOCTOR:
_____________________________________
RHEUMATOLOGIST:
_____________________________________
DERMATOLOGIST:
_____________________________________
ENDOCRINOLOGIST:
_____________________________________
NUTRITIONIST:
_____________________________________
OTHER CURRENT PHYSICIANS:
_____________________________________
HAVE YOU EVER BEEN DIAGNOSED WITH DRY EYE DISEASE OR OCULAR SURFACE DISEASE?
 YES
 NO
WHAT BOTHERS YOU THE MOST ABOUT YOUR DRY EYES?
____________________________________________________________________________
© 2013 HUDSON VALLEY EYE SURGEONS, PC
 NO
WHICH OF THE FOLLOWING SYMPTOMS DO YOU HAVE?
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BLURRED VISION
RED EYES
BURNING
ITCHING
LIGHT SENSITIVITY
WIND SENSITIVITY
DISCHARGE
EXCESSIVE TEARING
EYES FEEL TIRED, EYE FATIGUE
MUCOUS IN EYES
SWOLLEN EYELIDS
CRUSTING OF THE LASHES
FLUCTUATING VISION
FOREIGN BODY SENSATION (FEELS LIKE SOMETHING IS IN THE EYES)
CONTACT LENS DISCOMFORT
SANDY, GRITTY EYES
OTHER: ______________________________________________________________________________________
WHICH OF THE FOLLOWING SURGERIES HAVE YOU HAD ON YOUR EYES?
 CATARACT SURGERY
 RIGHT
DATE:________
 LEFT
DATE:________
 GLAUCOMA SURGERY
 RIGHT
DATE:________
 LEFT
DATE:________
 LASIK/PRK SURGERY
 RIGHT
DATE:________
 LEFT
DATE:________
 RETINA SURGERY
 RIGHT
DATE:________
 LEFT
DATE:________
 OTHER
________________________________________
 RIGHT
DATE:________
 LEFT
DATE:______
 OTHER
________________________________________
 RIGHT
DATE:________
 LEFT
DATE:______
© 2013 HUDSON VALLEY EYE SURGEONS, PC
OTHER MEDICAL ISSUES YOU HAVE BEEN DIAGNOSED WITH IN YOUR EYES? (FOR EXAMPLE, GLAUCOMA, CATARACTS, MACULAR DEGENERATION)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
DO YOU CURRENTLY WEAR CONTACT LENSES?
 YES
TYPE OF LENS: ______________________
CURRENT RX: _______________________
I HAVE BEEN WEARING FOR _____________ YEARS
I DISPOSE OF THE LENSES EVERY:
 1 day
 1 week
 2 weeks
SOLUTION I USE:  RENU
 1 month
 OPTIFREE
 3 months
 GENERIC
 OTHER ______________
 OTHER ______________
I WEAR MY CONTACT LENSES ___________ HOURS , ____________ DAYS A WEEK
I SLEEP IN MY LENSES:
 YES
 NO
I THROW MY CASE OUT HOW OFTEN:
 1 MONTH
 3 MONTHS
 6 MONTHS
 1 YEAR
 NEVER
 OTHER ______________
I CLEAN MY CASE WITH:
 TAP WATER
 DISHWASHER
© 2013 HUDSON VALLEY EYE SURGEONS, PC
 CONTACT LENS SOLUTION
 DO NOT CLEAN IT
 OTHER ______________
I HAVE HAD INFECTIONS OF MY EYES RELATED TO MY CONTACT LENSES:
 YES
 NO
HAVE YOU EVER WORN SAFIGEL CONTACT LENSES?:
 YES
 NO
 NO CURRENT CONTACT LENS WEAR
 PAST CONTACT LENS WEARER: WHEN DID YOU STOP? ___________________________
I STOPPED BECAUSE:
 INFECTIONS
 PAIN
 DRYNESS
 REDNESS
 COST
 DISCOMFORT
 OTHER _____________________
PLEASE LIST ALL YOUR CURRENT MEDICATIONS AND SUPPLEMENTS:
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
© 2013 HUDSON VALLEY EYE SURGEONS, PC
Are you taking any of the following medications:
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antihistamines/decongestants
anti-depressants or anti-anxiety
oral steroids/nasal steroids
hormone replacement therapy
oral contraceptives
sleeping pills
antihypertensives (i.e Beta Blockers)
accutane/oral acne treatment
diuretics “water pills” (i.e. LASIX, HCTZ)
fosamax
PLEASE LIST ALL YOUR CURRENT EYE DROPS:
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
_____________________________________________________________________________________________________________________________ _______________________
_____________________________________________________________________________________________________________________________ _______________________
ANY MEDICATION ALLERGIES OR OTHER ALLERGIES (I.E LATEX)?
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
© 2013 HUDSON VALLEY EYE SURGEONS, PC
PLEASE LIST ALL YOUR CURRENT MEDICAL DIAGNOSES:
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
DO YOU HAVE:
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THYROID DISEASE
ROSACEA
RHEUMATOID ARTHRITIS
DIABETES
LUPUS
SLEEP DISORDER
SARCOID
FACIAL SHINGLES
MULTIPLE SCLEROSIS (MS)
SJOGRENS SYNDOME
SEASONAL OR ENVIRONMENTAL ALLERGIES
DEPRESSION
PSORIASIS
HYPERTENSION
ACNE
© 2013 HUDSON VALLEY EYE SURGEONS, PC
DO YOU TAKE ANY NUTRITIONAL SUPPLEMENTS? PLEASE LIST THEM HERE:
_____________________________________________________________________________________________________________________________ _______________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________________
____________________________________________________________________________________________________________________________________________________
DO YOU TAKE ANY OMEGA 3 SUPPLEMENTS:
WHAT BRAND:
____________________________________________________________________________________________________________________________
HOW MUCH:
____________________________________________________________________________________________________________________________
HOW MUCH COMPUTER WORK DO YOU GENERALLY DO IN A TYPICAL DAY?
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NONE
1-2 HOURS
3-5 HOURS
6-8 HOURS
MORE THAN 8 HOURS A DAY
HOW MANY HOURS A DAY DO YOU TYPICALLY DRIVE?
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NONE
1-2 HOURS
3-5 HOURS
6-8 HOURS
MORE THAN 8 HOURS A DAY
© 2013 HUDSON VALLEY EYE SURGEONS, PC
WHAT IS YOUR OCCUPATION?
_____________________________________________________________________________________________________________________________ _______________________
 RETIRED
DO YOU SPEND MOST OF YOUR DAY INSIDE OR OUTSIDE?
 INSIDE
 OUTSIDE
IS THERE A FAN OR VENT IN CLOSE PROXIMITY TO THE AREA YOU DO MOST OF YOUR WORK ON A TYPICAL DAY?
 YES
 NO
IS THERE A FAN OR VENT IN CLOSE PROXIMITY TO THE AREA YOU SLEEP?
 YES
 NO
DO YOU FREQUENTLY TRAVEL IN AN AIRPLANE?
 YES
 NO
DESCRIBE THE FREQUENCY/AMOUNT OF AIR TRAVEL:
________________________________________________________________________________________
MY REGULAR HOBBIES INCLUDE
 READING
 TV WATCHING
 COMPUTER WORK
 OTHER
_______________________________________________________________________________________________
 OTHER
_______________________________________________________________________________________________
© 2013 HUDSON VALLEY EYE SURGEONS, PC
I CURRENTLY SMOKE:
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never
1-5 cigars/cigarettes a day
6-10 cigarettes a day
11-19 cigarettes a day
1-2 packs a day
MORE than 2 packs a day
 other substances
 FORMER SMOKER
WHEN DID YOU QUIT?
____________________________________________________________________________
____________________________________________________________________________
I CURRENTLY DRINK ALCOHOL:
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EVERY DAY
ABOUT EVERY OTHER DAY
ABOUT ONCE A WEEK
ABOUT ONCE A MONTH
ABOUT EVERY FEW MONTHS
ONCE A YEAR OR LESS
NEVER
I HAVE A DRY MOUTH:
 YES
 NO
I HAVE PREVIOUSLY BEEN EVALUATED FOR SJOGRENS SYNDROME:
 YES
 NO
I HAVE BEEN DIAGNOSED WITH SJOGRENS SYNDROME:
 YES
 NO
I HAVE BEEN TOLD I KEEP MY EYES OPEN WHEN I SLEEP
 YES
 NO
© 2013 HUDSON VALLEY EYE SURGEONS, PC
I REGULARY DRINK THESE CAFFEINATED BEVERAGES:
1-2 SERVINGS PER DAY
3-4 SERVINGS PER DAY
5 OR MORE SERVINGS PER DAY
COFFEE
(1 SERVIING=12 OZ= 35 MG caffeine)
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TEA
(1 SERVING= 16 OZ=62 MG caffeine)
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SODA
(1 SERVING=12 OZ= 35 MG caffeine)
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ENERGY DRINK (1 SERVING=8 OZ= 80 MG caffeine)
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OTHER ___________________________
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HOW MANY GLASSES (8 FL OZ) OF WATER DO YOU DRINK A DAY?
0
1-2
3-4
5-6
7-8
MORE THAN 8
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© 2013 HUDSON VALLEY EYE SURGEONS, PC
TREATMENT HISTORY
DO YOU CURRENTLY USE OR HAVE YOU USED THE FOLLOWING LUBRICATING DROPS (ARTIFICIAL TEARS)?
PLEASE RATE THESE TEARS ACCORDING TO THE RELIEF/COMFORT THAT THEY GAVE YOU.
DROP
MY FAVORITE
HELPED A LOT
HELPED A LITTLE
USELESS
BOTHERED MY EYES
HAVE NEVER USED
SYSTANE ULTRA
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SYSTANE GEL DROPS
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SYSTANE BALANCE
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SYSTANE PRESERVATIVE FREE
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GENTEAL GEL DROPS
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BLINK
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BLINK CONTACTS
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BLINK GEL DROPS
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BLINK PRESERVATIVE FREE
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REFRESH (OPTIVE)
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REFRESH PRESERV. FREE
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MURO 128 DROPS
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VISINE
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SOOTHE
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THERATEARS
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____________________
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OTHER
© 2013 HUDSON VALLEY EYE SURGEONS, PC
HOW MANY TIMES A DAY DO YOU USE ARTIFICIAL TEARS? __________________
DO YOU CURRENTLY USE OR HAVE YOU USED THE FOLLOWING NIGHT-TIME GELS/OINTMENTS?
PLEASE RATE THESE GELS/OINTMENTS ACCORDING TO THE RELIEF/COMFORT THAT THEY GAVE YOU.
MY FAVORITE
HELPED A LOT
HELPED A LITTLE
USELESS
BOTHERED MY EYES
HAVE NEVER USED
SYSTANE NIGHT GEL
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GENTEAL NIGHT GEL
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LACRILUBE
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MURO OINTMENT
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BACITRACIN OINTMENT
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ERYTHROMYCIN OINTMENT 
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OTHER
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HOW MANY TIMES A DAY DO YOU USE GELS OR OINTMENTS? ___________
HAVE YOU EVER USED RESTASIS?
 YES
 NO
© 2013 HUDSON VALLEY EYE SURGEONS, PC
HOW WOULD YOU RATE YOUR EXPERIENCE WITH RESTASIS:
HELPED A LOT
RESTASIS
HELPED A LITTLE
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USELESS
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BOTHERED MY EYES
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HAVE NEVER USED
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NOT SURE
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DO YOU TAKE ANY DROPS TO “GET THE RED OUT”?
 YES
WHICH DROPS? ______________________________________
 NO
HAVE YOU EVER HAD PUNCTAL PLUGS INSERTED OR PUNCTAL CAUTERY?
 YES
 RIGHT EYE
 LEFT EYE
 NO
How would you rate your experience with PUNCTAL PLUGS OR PUNCTAL CAUTERY:
HELPED A LOT
HELPED A LITTLE
USELESS
BOTHERED MY EYES
HAVE NEVER USED
NOT SURE
PUNCTAL PLUGS
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PUNCTAL CAUTERY
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© 2013 HUDSON VALLEY EYE SURGEONS, PC
HAVE YOU EVER HAD ANY OF THE FOLLOWING TREATMENTS AND HOW DID THEY AFFECT YOUR EYES?
HELPED A LOT
HELPED A LITTLE
USELESS
BOTHERED MY EYES
HAVE NEVER USED
NOT SURE
LOTEMAX
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PUNCTAL PLUGS
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PUNCTAL CAUTERY
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OMEGA 3 FATTY ACIDS
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LID SCRUBS
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INTENSE PULSED LIGHT
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LIPIFLOW
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LACRISERTS
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RESTASIS
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STEROIDS
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DOXYCYCLINE
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AZASITE
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ERYTHROMYCIN OINTMENT 
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BANDAGE CONTACT LENS
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LID GLAND EXPRESSION
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LID GLAND PROBING
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OCUSOFT 360 PROGRAM
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TEARS AGAIN SPRAY
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VITAMIN SUPPLEMENTS
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WHICH SUPPLEMENTS?
______________________________________
© 2013 HUDSON VALLEY EYE SURGEONS, PC
HAVE YOU EVER HAD ANY OF THE FOLLOWING TREATMENTS AND HOW DID THEY AFFECT YOUR EYES?
HELPED A LOT
HELPED A LITTLE
USELESS
BOTHERED MY EYES
HAVE NEVER USED
NOT SURE
RETAINE PRODUCTS
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TRANQUILEYES
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MOISTURE GOGGLES
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PROKERA
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SERUM EYE DROPS
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SAFIGEL CONTACT LENS
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ACUPUNCTURE
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NUTRITIONIST
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END OF QUESTIONNAIRE
PLEASE REMEMBER TO RETURN THIS QUESTIONNAIRE AS SOON AS POSSIBLE TO HUDSON
VALLEY EYE SURGEONS AND AT LEAST ONE WEEK PRIOR TO YOUR APPOINTMENT
© 2013 HUDSON VALLEY EYE SURGEONS, PC