Name

First Name

Last Name

Phone

Email

I use moisturizing eye drops or ointments:

Sometime this week, my eyes have felt:

I sometimes have difficulty with my eyes when:

I sometimes experience:

Blurred vision

Fluctuating vision

Some other vision problem

Frequent blinking

None of the above

Problems with dry eyes interfere with my job / activities I enjoy.

Always

Often

Sometimes

Never

I am ready to discuss with an eye doctor the latest new treatments for dry eye!

Yes

No

How do you prefer to be contacted?

Phone only

Email only

No preference

Dry Eye Quiz

Ready To See Clearly?