World Eyeglasses & Personal EyeCare

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www.WorldEyeGlasses.com

6201 N. Federal Hwy, Fort Lauderdale, Florida 33308 (ON FEDERAL HWY. Between Commercial & Atlantic Blvd.- In SAME Plaza as OUTBACK & SUBWAY)

About Dr. Gary Enker
Owner & Board Certified Optometrist

World Eyeglasses & Personal Eyecare
www.WorldEyeGlasses.com
Serving Fort Lauderdale, Florida Since 1991!

6201 N. Federal Hwy Fort Lauderdale,
33308 (ON Federal Hwy Between Commercial & Atlantic Blvd.- In Same Plaza as OUTBACK & SUBWAY)
954-491-7141

Visit AllAboutVision.com for guides to glasses and contacts, and to learn about eye health topics such as cataracts and glaucoma

You may Also Print & Fax ( Fax #: 954-491-7164 )

Eye Care's Dry Eye Evaluation Questionnaire

First Name

Last Name

Phone

Email

How Often do you have ...?

Redness

Never
Sometimes
Frequently
Always

Score:

Sandy or Gritty Sensation

Never
Sometimes
Frequently
Always

Score:

Itching

Never
Sometimes
Frequently
Always

Score:

Excess Watering

Never
Sometimes
Frequently
Always

Score:

Burning

Never
Sometimes
Frequently
Always

Score:

Excess Mucous

Never
Sometimes
Frequently
Always

Score:

Blurred Vision

Never
Sometimes
Frequently
Always

Score:

Are your eyes sensitive to ...?

Smoke

Never
Sometimes
Frequently
Always

Score:

Light

Never
Sometimes
Frequently
Always

Score:

Air Pollution

Never
Sometimes
Frequently
Always

Score:

Wind

Never
Sometimes
Frequently
Always

Score:

Heaters

Never
Sometimes
Frequently
Always

Score:

Air Conditioning

Never
Sometimes
Frequently
Always

Score:

Contact Lenses

Never
Sometimes
Frequently
Always

Score:

How often do you use ...?

Anti-Depressants

Never
Sometimes
Frequently
Always

Score:

Redness Reducing Eye Drops

Never
Sometimes
Frequently
Always

Score:

Decongestants

Never
Sometimes
Frequently
Always

Score:

Antihistamines

Never
Sometimes
Frequently
Always

Score:

Blood Pressure Medication

Never
Sometimes
Frequently
Always

Score:

Artificial Tear Drops

Never
Sometimes
Frequently
Always

Score:

Hormones

Never
Sometimes
Frequently
Always

Score:

Oral Contraceptives

Never
Sometimes
Frequently
Always

Score:

Diuretics

Never
Sometimes
Frequently
Always

Score:

Ulcer Medication

Never
Sometimes
Frequently
Always

Score:

Tranquilizers

Never
Sometimes
Frequently
Always

Score:

Beta Blockers

Never
Sometimes
Frequently
Always

Score:

Incontinence Therapies

Never
Sometimes
Frequently
Always

Score:

Average daily computer time

Hours

0 Hrs
1-2 Hrs
3-4 Hrs
Over 4 Hrs

Score:

Have you ever been diagnosed with…?

Thyroid Abnormalities

Yes
No

Score:

Rheumatoid Arthritis

Yes
No

Score:

Asthma

Yes
No

Score:

Diabetes

Yes
No

Score:

Glaucoma

Yes
No

Score:

Are You...?

Over 45

Yes
No

Score:

Post-menopausal

Yes
No

Score:

Considering refractive surgery

Yes
No

Score:

Do you…?

Experience Contact Lens discomfort

Yes
No

Score:

Get eyestrain

Yes
No

Score:

Blink your eyes excessively

Yes
No

Score:

As an Adult…?

Have you had blemishes on your face?

Yes
No

Score:

If your scored 30 or higher you may have dry eyes. Please call our office for an evaluation

Total Score:

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