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 read our Privacy Policy on how we collect and use your health information. 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) ItchyCrustySwollenProducing discharge 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: