Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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? 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: 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: 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? 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? 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: 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: 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) TEA (1 SERVING= 16 OZ=62 MG caffeine) SODA (1 SERVING=12 OZ= 35 MG caffeine) ENERGY DRINK (1 SERVING=8 OZ= 80 MG caffeine) OTHER ___________________________ 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 © 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 SYSTANE GEL DROPS SYSTANE BALANCE SYSTANE PRESERVATIVE FREE GENTEAL GEL DROPS BLINK BLINK CONTACTS BLINK GEL DROPS BLINK PRESERVATIVE FREE REFRESH (OPTIVE) REFRESH PRESERV. FREE MURO 128 DROPS VISINE SOOTHE THERATEARS ____________________ ____________________ 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 GENTEAL NIGHT GEL LACRILUBE MURO OINTMENT BACITRACIN OINTMENT ERYTHROMYCIN OINTMENT OTHER ____________________ ____________________ 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 USELESS BOTHERED MY EYES HAVE NEVER USED NOT SURE 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 PUNCTAL CAUTERY © 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 PUNCTAL PLUGS PUNCTAL CAUTERY OMEGA 3 FATTY ACIDS LID SCRUBS INTENSE PULSED LIGHT LIPIFLOW LACRISERTS RESTASIS STEROIDS DOXYCYCLINE AZASITE ERYTHROMYCIN OINTMENT BANDAGE CONTACT LENS LID GLAND EXPRESSION LID GLAND PROBING OCUSOFT 360 PROGRAM TEARS AGAIN SPRAY VITAMIN SUPPLEMENTS 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 TRANQUILEYES MOISTURE GOGGLES PROKERA SERUM EYE DROPS SAFIGEL CONTACT LENS ACUPUNCTURE NUTRITIONIST 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