OSD Clinic Questionnaire

Patient Information

First name*

Last name*

Date of birth*

Phone

Email*

Reason for Visit (please include treatment goals or complaints if pertinent):*

Referred By:

Patient Medical History

Medical 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

None

Smoker*

Current

Never smoked

Previous smoker

Smoker from when, until when?

Family history*

Skin disease, i.e. rosacea, eczema, psoriasis

Autoimmune disease, i.e. rheumatoid arthritis, Sjorgren’s

Cancer

None

Cancer; if yes, what type?

Current Medications:*

OTC pain medication

Allergy meds/decongestants

Oral contraceptives

Antacids

Hormone Replacement Therapy

Acne medication

Other

None

Other 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

None

If yes, past treatment:

Eye Surgery*

Lasik

PRK

Cataract

Lid surgery

Other

None

Eye Surgery Other: If yes

Contact Lens History*

Never, but interested

Never, and not interested

Discontinued due to intolerance

Discontinued due to other reason

Current with no problems

Current with limitations

Please explain

Years wearing contact lenses

Type of Lens:

Daily Disposable

2 Week Disposable

Monthly Disposable

Hard/Gas-Permeable

Other

Other type of Lens

Do you sleep in your contact lenses?

Yes

Sometimes

Contact lens solution:

Opti-free

Renu

Clear Care

Other

Current Glasses

How 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 Treatment

Current eye drops, ointments, wipes or sprays (prescription and/or over the counter)?

Report the type of symptoms you experience and when they occur

Dryness, Grittiness, or Scratchiness*

Yes

Past 72 hours

Within the past 3 month

Soreness or Irritation*

Yes

Past 72 hours

Within the past 3 month

Burning or Watering*

Yes

Past 72 hours

Within the past 3 month

Eye Fatigue*

Yes

Past 72 hours

Within the past 3 month

Report the frequency of symptoms:

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness, or Scratchiness*

Soreness or Irritation*

Burning or Watering*

Eye Fatigue*

Report 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 tasks

Dryness, Grittiness, or Scratchiness*

Soreness or Irritation*

Burning or Watering*

Eye Fatigue*

Convergence Insufficiency Symptom Survey

Please select the answer that best describes your average day.

Do your eyes feel tired when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do your eyes feel uncomfortable when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you have headaches when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you feel sleepy when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you lose concentration when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you have trouble remembering what you have read?*

Never

Infrequently

Sometimes

Often

Always

Do you have double vision when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you see the words move, jump, swim, or appear to float on the page when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you feel like you read slowly?*

Never

Infrequently

Sometimes

Often

Always

Do your eyes ever hurt when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do your eyes ever feel sore when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you feel a "pulling" feeling around your eyes when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you notice the words blurring or coming in and out of focus when reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you lose your place while reading or doing close work?*

Never

Infrequently

Sometimes

Often

Always

Do you have to re-read the same line of words when reading?*

Never

Infrequently

Sometimes

Often

Always

Lifestyle Questionnaire

How 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 hours

Air quality at work?*

Seems normal

Dry; I use a humidifier

Dry; no humidifier

Air quality at home?*

Seems normal

Dry; I use a humidifier

Dry; no humidifier

Do you sleep with a fan on?*

Yes

How many hours of sleep do you get per night?*

< 4 hours

4-5 hours

> 6 hours

Do you have pets?*

Yes

How many hours do you spend driving?*

< 1 hour

1-2 hours

> 2 hours

How much water do you drink a day?*

< 2 glasses

3-5 glasses

6-8 glasses

> 8 glasses

Do you wear eye make-up?*

Yes

Do you remove it before bed?*

Yes

Sometimes

Do 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

None

Are you currently under the care of a Dermatologist?

Yes

if 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

Other

What other cosmetic procedures?

Do you use Eyelash Growth Serum (i.e. Latisse, Rodan and Fields, etc.)?*

Yes

Do you use a CPAP machine?*

Yes

What 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: technician@metroeye.biz

We look forward to seeing you!

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OSD Clinic Patient Questionnaire

Patient Information

Patient Medical History

Current Glasses

Current Eye Treatment

Report the type of symptoms you experience and when they occur

Report the frequency of symptoms:

Report the severity of your symptoms using the rating list below:

Convergence Insufficiency Symptom Survey

Lifestyle Questionnaire