Ocular Surface Questionnaire

DEMOGRAPHIC INFORMATION

1. Please check any that apply to you. Are you:
____ Female?
____ Pregnant or Nursing
____ Over age 40?
____ A Tobacco user?
____ Using a computer more than 1 hour a day? ____ hours
____ Reading for more than 1 hour per day?
____ A contact lens wearer
____ Consume 4 or more caffeinated beverages per day?
____ Traveling in airplanes more than twice per month?
____ Routinely using a ceiling fan in your bedroom?
____ Getting less than 7 hours of sleep per night in an average week?

Approximately how many glasses of water do you drink per day?
____ 3 or more
____ Less than 3

Approximately how many servings of fish do you eat per week?
____ 3 or more
____ Less than 3

Do you take omega-3 supplements such as fish oil?
___ Yes    ____ No    Name Brand ______________________________

 2. How many medications (different pills) do you currently take?
____ 3 or more
____ Less than 3

 3. Do you currently take any of the following medications? (Please check all that apply)
____ Antihistamines
____ Anti-depressants
____ (LASIX)
____ Active bladder therapy
____ C-Pap Machine
____ Beta blockers
____ Hormone Replacement therapy
____ Diuretics
____ Radiation therapy
____ Accutane (even previously)

4. Do you use any of the following eye drops? (Please check all that apply)
____ Glaucoma drops
____ Allergy drops
____ Others __________________________________________________________

SYMPTOMS

1. Over the past month, which of the following ocular symptoms have you experienced?
____ Stinging
____ Tearing
____ Itching
____ Grittiness
____ Burning
____ Decreased contact lens wearing time
____ Redness
____ Occasional blurred vision
____ Dryness
____ Glare
____ Night driving problems
____ Ocular discomfort (aching)
____ Light sensitivity
____ Dry mouth

2. Have you ever had eye surgery (LASIK, PRK, Cataract Surgery, other)?
____ No     ____ Yes, please specify ______________________________

SYSTEMIC DISEASE

1. Which of following conditions have you been diagnosed with? (Check all that apply)
____ Thyroid disease
____ Arthritis
____ Diabetes
____ Lupus
____ Acne/Rosacea
____ Sleep disorders
____ Sarcoidosis
____ Facial herpes zoster (shingles)
____ Heptatitis C
____ Androgen deficiency

Other ocular questions

____ Yes   ____ No  Do you notice mattering on your eyelids when you wake in the morning?
____ Yes   ____ No  Are your eyelids swollen or red along the lash margins?
____ Yes   ____ No  Do you experience burning in the morning?
____ Yes   ____ No  Do you have a significant amount of crusting on your eyelids?
____ Yes   ____ No  Does your vision fluctuate from clear to blurry, especially in the morning (including after reading, watching TV, computer or driving)?

____ Yes   ____ No  Do you use or have you tried Artificial Tears?
Brand name of Artificial Tears______________________________________

When used, how long does/did the relief last after you instill a drop of artificial tears?
____ Less than 15 minutes
____ Less than 1 hour
____ More than 1 hour

When used, typically how many artificial tear drops do or did you use per day?
____ 4 or more
____ 3 or less