Ocular Surface Disease Extended History

Ocular Surface Disease Extended History

Name *


SYMPTOMS

Please circle the words that describe your symptoms


In your own words, please describe symptom onset and how your eyes feel most days:

Example: When did you first notice your symptoms? One eye? Both eyes? Constant or intermittent? Are you more symptomatic at certain times of the day (e.g. late afternoon, when you wake up) or location (e.g. work, home.)?


Which of the above treatments provide relief? To what degree (e.g. 50%)? For how long (e.g. 1-2 hours)?
Example: The Systane Balance helps about 50% for about 2 hours.


If you can recall, it would be helpful to know what drops, gels, ointments or procedures (e.g. Restasis, plugs, Lipiflow, IPL) that you have tried previously:
Example: I've tried some type of fish oil and Restasis


SYMPTOMS THAT MAY BE ASSOCIATED WITH OCULAR SURFACE DISEASE

Please check any boxes that apply:


AESTHETIC & SKIN CARE HISTORY

Have you had permanent eyeliner applied/tattooed?

Have you used lash extensions (or considering in the future)?

Are you using a lash lengthening serum?

Have you used, or planning to use, injectables or fillers (e.g. Botox, Dysport, Xeomin, Juvederm, etc.)

Have you had any eyelid or facial surgery?


CONTACT LENS HISTORY (WE WANT TO OPTIMIZE YOUR COMFORT)

1. Do you currently wear contact lenses? If yes, please answer questions 3-7

2. Have you tried contact lenses but unable to continue due to comfort?

3. How many hours/day?

4. How many hours/day?

5. How many hours can you wear your contact lenses prior to noticing a decline in comfort or feel the need to use eye drops?

6. What cleaning system do you use (if not using single use lenses)?

7. How often do you insert a fresh lens?

VITAMINS & SUPPLEMENTS

Please list any vitamins or nutritional supplements you take on a regular basis:
VERY IMPORTANT - PLEASE BRING PRODUCTS WITH YOU TO YOUR APPOINTMENT OR TAKE PHOTOS OF PRODUCT FRONT AND BACK LABELS. YOU MAY ALSO CHOOSE TO LIST PRODUCTS BELOW


Product:


Dose:


LIFESTYLE

Many factors impact our tear production, from what we eat and drink to our jobs and hobbies, all can play a role in our symptoms. Small lifestyle modifications often contribute to relief

How many ounces of water do you drink per day?

How many caffeinated drinks per day (e.g. coffee, tea, energy drinks)?

Do you drink soda or diet soda?

On average, how many beverages containing alcohol (beer, wine, spirits) do you consume per week?

Do you (or a bed partner) use a c-pap device?

Do you use ceiling fan(s)?

Do you frequently drive long distances for work or pleasure?

Do you travel by airplane? If so, how many trips per year

Does your workplace create any environmental challenges (e.g. fans, no air conditioning, etc.)?

How many hours of sleep do you average?

Check the boxes that apply if you use any of the following products that are known to be associated with dry eye symptoms:


HORMONE RELATED TEAR PRODUCTION

Our hormones play many roles in our body, including tear production. Please list any hormone-related issues past or present.
e.g. thyroid disease, irregular periods, PCOS, menopause, low testosterone, adrenal insufficiency or exhaustion, use of birth control (e.g. oral contraceptives, IUD’s), synthetic or biodentical hormones


Are you, or could you, be pregnant?

Quick Links
Helpful Articles
Eye Care Services

All Eye
Care Services

Learn More
Contact Us

Keep
In Touch

Contact Us