Self Test | The Dry Eye Treatment Center

Your Name *

Your Phone *

Your Email *

Have you ever been diagnosed with, or do you think you might have, dry eyes? *

Yes
No

Do you have environmental allergies? *

Yes
No

Do you spend more than 2 hours per day reading a computer screen, tablet, cell phone, newspapers/magazines, documents, books, watching TV, or driving a car? *

Yes
No

Do you ever experience any of the following eye symptoms? Please check all that apply.

Do you wear contact lenses? *

Yes
No

Do you use any over-the-counter eye drops such as artificial tears, allergy drops, Visine, etc.? *

Yes
No

Do you use any prescription eye drops? *

Yes
No

Do you take, or have you ever taken, any of the following medications? Please check all that apply.

Antihistamines/decongestants
Antidepressant or anti-anxiety medications
Birth control pills
Hormone replacement therapy (estrogen and/or progesterone)
Anti-hypertensives (e.g., diuretics, beta-blockers)
Accutane
Chemotherapy and/or radiation
Pain medications