Dry Eye Survey

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* 1. I am a

Male

Female

Other

Choose Not to Specify

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* 2. How old are you?

Under 18

18-25

26-35

36-45

46-55

56+

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* 3. Which of the following symptoms are you experiencing?

Dryness

Itching

Excessive tearing

Redness

Scratchy, gritty feeling

Light sensitivity

Blurry or fluctuating vision

Trouble wearing contact lenses

Anxiety

Crusty & matted lids

Burning sensation

Other

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* 4. What time of the day are your eyes at their driest?

Morning

Afternoon

Evening

All Day

It Varies

On the Computer

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* 5. Are you currently using eye drops?

Yes

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* 6. Have you seen a dry eye specialist who has done an official dry eye workup and diagnosis of your eye problem?

Yes

I don't know

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* 7. Have you ever been diagnosed with any eye diseases or auto-immune conditions?

Yes

I don't know

Dry Eye Survey

Question Title

* 1. I am a

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* 2. How old are you?

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* 3. Which of the following symptoms are you experiencing?

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* 4. What time of the day are your eyes at their driest?

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* 5. Are you currently using eye drops?

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* 6. Have you seen a dry eye specialist who has done an official dry eye workup and diagnosis of your eye problem?

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* 7. Have you ever been diagnosed with any eye diseases or auto-immune conditions?

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* 8. How to contact you - Name

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* 9. How to contact you - Phone Number

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* 10. How to contact you - Email Address