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    Dry Eye Q PDF

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    jigna218655
    The patient completed a dry eye questionnaire providing information about symptoms, medical history, family history, and medications. They reported experiencing dry eyes, redness, grittiness, irritation from outside air, and sensitivity to light for various periods of time. Regarding medical history, the patient indicated no eye surgeries or injuries but checked boxes for other eye problems and arthritis. They also noted a family history of glaucoma, cataracts, and diabetes. Several medications were listed as possibly exacerbating dry eye symptoms, including antihistamines, diuretics, oral contraceptives, and blood pressure pills.

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    Dry Eye Q PDF

    Uploaded by

    jigna218655
    14 views1 page
    The patient completed a dry eye questionnaire providing information about symptoms, medical history, family history, and medications. They reported experiencing dry eyes, redness, grittiness, irritation from outside air, and sensitivity to light for various periods of time. Regarding medical history, the patient indicated no eye surgeries or injuries but checked boxes for other eye problems and arthritis. They also noted a family history of glaucoma, cataracts, and diabetes. Several medications were listed as possibly exacerbating dry eye symptoms, including antihistamines, diuretics, oral contraceptives, and blood pressure pills.

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    The patient completed a dry eye questionnaire providing information about symptoms, medical history, family history, and medications. They reported experiencing dry eyes, redness, grittiness, irritation from outside air, and sensitivity to light for various periods of time. Regarding medical history, the patient indicated no eye surgeries or injuries but checked boxes for other eye problems and arthritis. They also noted a family history of glaucoma, cataracts, and diabetes. Several medications were listed as possibly exacerbating dry eye symptoms, including antihistamines, diuretics, oral contraceptives, and blood pressure pills.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    14 views1 page

    Dry Eye Q PDF

    Uploaded by

    jigna218655
    The patient completed a dry eye questionnaire providing information about symptoms, medical history, family history, and medications. They reported experiencing dry eyes, redness, grittiness, irritation from outside air, and sensitivity to light for various periods of time. Regarding medical history, the patient indicated no eye surgeries or injuries but checked boxes for other eye problems and arthritis. They also noted a family history of glaucoma, cataracts, and diabetes. Several medications were listed as possibly exacerbating dry eye symptoms, including antihistamines, diuretics, oral contraceptives, and blood pressure pills.

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    of 1

    DRY EYE PATIENT QUESTIONNAIRE

    Name: _________________________________ Age: _________

    Sex: M

    Date: _________________ Occupation: _________________________________________________

    What is the main reason that you made an appointment for today? ______________________________
    _____________________________________________________________________________________
    ___________________________________________________________________________________
    Have you had any of the following conditions? (Check all that Apply)
    Problem
    For how long?
    Eyes Feel Dry
    ____________
    Red/Infected Eyes
    ____________
    Feeling of Something in Eye ___________
    Grittiness
    ____________
    Eyes Feel Tired
    ____________
    Irritation from Swimming ____________
    Trouble Swallowing Food ____________
    Blurred Vision
    ____________

    Problem
    For how long?
    Discharge from Eyes
    ____________
    Itching
    ____________
    Sandy Feeling
    ____________
    Constant Tearing
    ____________
    Irritation from Outside Air____________
    Sensitivity to Light
    ____________
    Eyes Burn
    ____________
    Use Eye Drops
    ____________

    Have you had any of the following? (Check all that Apply)
    Yes

    Condition
    Eye Surgery
    Eye Injury
    Other Eye Problems

    Describe
    _________________________________________________________
    _________________________________________________________
    _________________________________________________________

    Have your or any close relative had any of the following conditions? (Check all that Apply)
    Yourself
    Relative
    Yourself
    Relative
    Glaucoma

    Cataracts

    Systemic Lupus

    Heart Disease

    Arthritis

    Diabetes

    Other Systemic Disease

    Describe________________________________________________________________________

    Have your eyes become dry since taking any of these medications? (Check all that Apply)
    Antihistamines
    Diuretics (water pills)
    Oral Contraceptives
    Blood Pressure Pills
    Pills for acne
    Hormone Replacement Therapy
    Sleeping Tablets

    Other_________________________________________
    APC94AQ09

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