OSD Clinic Patient Questionnaire"*" indicates required fields Δ Step 1 of 119%Patient InformationFirst name*Last name*Date of birth*PhoneEmail* Reason for Visit (please include treatment goals or complaints if pertinent):*Referred By:Patient Medical HistoryMedical History* Hypertension Diabetes Skin disease, i.e. rosacea, eczema, psoriasis Thyroid disease Hormone replacement therapy Allergies Dry mouth or trouble swallowing Achy joints or chronic pain GI upset or heartburn Chronic fatigue Cancer Autoimmune disease Alcoholism Insomnia NoneSmoker* Current Never smoked Previous smokerSmoker from when, until when?Family history* Skin disease, i.e. rosacea, eczema, psoriasis Autoimmune disease, i.e. rheumatoid arthritis, Sjorgren’s Cancer NoneCancer; if yes, what type?Current Medications:* OTC pain medication Allergy meds/decongestants Oral contraceptives Antacids Hormone Replacement Therapy Acne medication Other NoneOther medication:Please list name of medications and dosage.Current Supplements:Please list any supplements and dosage.Patient Ocular History* Glaucoma Eye injury Blepharitis or other eyelid disorder Previous diagnosis of dry eye or ocular surface disease NoneIf yes, past treatment:Eye Surgery* No Lasik PRK Cataract Lid surgery Other NoneEye Surgery Other: If yesContact Lens History* Never, but interested Never, and not interested Discontinued due to intolerance Discontinued due to other reason Current with no problems Current with limitationsPlease explainYears wearing contact lensesType of Lens: Daily Disposable 2 Week Disposable Monthly Disposable Hard/Gas-Permeable OtherOther type of LensDo you sleep in your contact lenses? Yes No SometimesContact lens solution: Opti-free Renu Clear Care OtherOther contact lens solutionDo you use contact lens re-wetting drops or artificial tears? Yes No SometimesName of drops:Current GlassesHow old is your current glasses prescription?When was your last refraction (glasses prescription update)?How often do you wear your glasses (or for what purpose/tasks)?Any pertinent problems/concerns regarding glasses wear?Current Eye TreatmentCurrent eye drops, ointments, wipes or sprays (prescription and/or over the counter)?Report the type of symptoms you experience and when they occurDryness, Grittiness, or Scratchiness* Yes No Past 72 hours Within the past 3 monthSoreness or Irritation* Yes No Past 72 hours Within the past 3 monthBurning or Watering* Yes No Past 72 hours Within the past 3 monthEye Fatigue* Yes No Past 72 hours Within the past 3 monthReport the frequency of symptoms: 0 = Never 1 = Sometimes 2 = Often 3 = ConstantDryness, Grittiness, or Scratchiness* 0 1 2 3Soreness or Irritation* 0 1 2 3Burning or Watering* 0 1 2 3Eye Fatigue* 0 1 2 3Report the severity of your symptoms using the rating list below: 0 = No problems 1 = Tolerable: not perfect, but not uncomfortable 2 = Uncomfortable: irritating, but does not interfere with my day 3 = Bothersome: irritating and interferes with my day 4 = Intolerable: unable to perform my daily tasksDryness, Grittiness, or Scratchiness* 0 1 2 3 4Soreness or Irritation* 0 1 2 3 4Burning or Watering* 0 1 2 3 4Eye Fatigue* 0 1 2 3 4Convergence Insufficiency Symptom SurveyPlease select the answer that best describes your average day.Do your eyes feel tired when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo your eyes feel uncomfortable when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you have headaches when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you feel sleepy when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you lose concentration when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you have trouble remembering what you have read?* Never Infrequently Sometimes Often AlwaysDo you have double vision when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you see the words move, jump, swim, or appear to float on the page when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you feel like you read slowly?* Never Infrequently Sometimes Often AlwaysDo your eyes ever hurt when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo your eyes ever feel sore when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you feel a "pulling" feeling around your eyes when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you notice the words blurring or coming in and out of focus when reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you lose your place while reading or doing close work?* Never Infrequently Sometimes Often AlwaysDo you have to re-read the same line of words when reading?* Never Infrequently Sometimes Often AlwaysLifestyle QuestionnaireHow many hours do you spend in front of a computer, phone, or ipad/device?* < 1 hour 1-3 hours 4-6 hours 7-9 hours > 9 hoursAir quality at work?* Seems normal Dry; I use a humidifier Dry; no humidifierAir quality at home?* Seems normal Dry; I use a humidifier Dry; no humidifierDo you sleep with a fan on?* Yes NoHow many hours of sleep do you get per night?* < 4 hours 4-5 hours > 6 hoursDo you have pets?* Yes NoHow many hours do you spend driving?* < 1 hour 1-2 hours > 2 hoursHow much water do you drink a day?* < 2 glasses 3-5 glasses 6-8 glasses > 8 glassesDo you wear eye make-up?* Yes NoDo you remove it before bed?* Yes No SometimesDo you use any make-up, lotions/creams, or cosmetics with the following ingredients?* Salicylic acid Benzoyl Peroxide Sodium lauryl/laureth sulfate Parabens Retinoic acid, Triretinoin, Retin-A, Retinol Formaldehyde and Formaldehyde-Releasing Preservatives: Formaldehyde, Quaternium-15, DMDM hydantoin, Imidazolidinyl urea, Diazolidinyl urea, Polyoxymethylene urea, Sodium hydroxymethylglycinate, 2-bromo-2-nitropropane-1,3-diol (bromopol), and Glyoxal NoneAre you currently under the care of a Dermatologist? Yes Noif Yes, please specify what for and any treatments/medications you are currently using.Have you had any cosmetic procedures?* Blepharoplasty i.e. lid surgery Botox Intense Pulsed Light Therapy (IPL) Lash Extensions Tattooed Make-up None OtherWhat other cosmetic procedures?Do you use Eyelash Growth Serum (i.e. Latisse, Rodan and Fields, etc.)?* Yes NoDo you use a CPAP machine?* Yes NoWhat are your hobbies?*Please use the following space to remark on any other concerns or factors that you believe may be contributing to your symptoms.Please click the "Submit" button below, to provide our eye care team with your completed questionnaire. We welcome you to contact the office with any additional questions or concerns. Phone: 414-727-5888 Email: [email protected] We look forward to seeing you!Google reCAPTCHA - Privacy - Terms
