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Dry Eye Syndrome Questionaire
Questionnaire

Please fill out this questionnaire, print and take to your next doctor's visit to assist your eye care professional in evaluating your symptoms.

Please check the appropriate response:

How often do you have these eye problems?

Redness never rarely commonly always

Sandy-gritty feeling never rarely commonly always

Itching never rarely commonly always

Excess watering never rarely commonly always

Burning never rarely commonly always

Excess mucous never rarely commonly always

Blurry Vision helped by blinking never rarely commonly always

Are your eyes sensitive to these conditions?

Smoke never rarely commonly always

Light never rarely commonly always

Air Pollution never rarely commonly always

Wind never rarely commonly always

Computer Screens never rarely commonly always

Heaters never rarely commonly always

Air Conditioning never rarely commonly always

Contact Lenses never rarely commonly always

How often do you use these medications?

Anti-Depressants never rarely commonly always

Redness Reducing Eye Drops never rarely commonly always

Decongestants never rarely commonly always

Antihistamines never rarely commonly always

Blood Pressure Medicine never rarely commonly always

Artificial Tears never rarely commonly always

Hormones never rarely commonly always

Oral Contraceptives never rarely commonly always

Diuretics never rarely commonly always

Ulcer Medication never rarely commonly always

Tranquilizers never rarely commonly always

Beta Blockers never rarely commonly always 

Have you been diagnosed with any of these conditions?

Thyroid Abnormality No Yes

Rheumatoid Arthritis No Yes

Asthma No Yes

Diabetes No Yes

Glaucoma? No Yes

Lupus No Yes

Are you over 50? No Yes

Do you experience contact lens discomfort? No Yes

Are you post menopausal? No Yes

Do you get eye strain ? No Yes

Do you blink your eyes excessively? No Yes

Are you considering refractive surgery? No Yes

Please fill out this questionnaire, print and take to your next doctor's visit to assist your eye care professional in evaluating your symptoms.


Katena Products, Inc.
4 Stewart Ct.
Denville, NJ 07834
Phones: 1-973-989-1600 • Toll free (USA): 1-800-225-1195
Fax 973.989.8175 • E-mail:
info@katena.com
© 2017 Katena Products, Inc.

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