Thank you for attending Insight Eye Surgery

    Insight Eye Surgery requests information about your dry eye symptoms before your attend for your appointment. Your responses will be discussed at the appointment.

    Background reading on dry eye can be found on our website here.

    Please select your answers for each of the following:

    SYMPTOMS

    1. How long have you experienced dry eye symptoms for?

    Less than 6 monthsUp to 2 years2 Years+

    2. Was there a triggering event?

    YesNo

    3. Is your vision effected by your symptoms?

    YesNo

    If YES does your vision clear upon blinking?

    YesNo

    4. Are your symptoms much worse in l eye than the other?

    YesNo

    5. Are your eyes? (tick all that apply)

    6. Have you had a severe conjunctivitis?

    YesNo

    7. Have you had styes or cysts around the eye?

    YesNo

    8. Do you have a dry mouth?

    YesNo

    ENVIRONMENTAL FACTORS

    9. Do you wear contact lenses?

    YesNo

    10. Have you had LASIK or any other surface laser vision correction?

    YesNo

    11. Have you had any eye lid surgery e.g. skin reduction or skin cancer removal?

    YesNo

    12. Have you had a chemical burn to your eyes?

    YesNo

    13. Are you a smoker?

    YesNo

    14. Do you wear mascara on a regular basis?

    YesNo

    15. Do you use a screen for long periods of time on a daily basis?

    YesNo

    MEDICAL FACTORS

    16. Do you have any autoimmune disorders?

    YesNo

    17. Do you or have you ever taken oral Accutane, topical isotretinoin (Retrieve cream)?

    YesNo

    18. Do you take medication which can cause dry eyes for example antihistamines or antidepressants?

    YesNo

    19. Are you postmenopausal or do you take any hormonal blockers?

    YesNo

    20. Are you on any glaucoma drops such as Xalatan?

    YesNo

    Thank you for your responses.

    Enter your full name so we can identify your response (otherwise this form will not be able to be submitted):

    Submit your answers by pressing the submit button below: