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MIDDLETOWN EYE CARE
DRY EYE SELF-TEST

MIDDLETOWN EYE CARE DRY EYE SELF-TEST

DRY EYE SELF-TEST

First Name *
Last Name *
Phone *
Email *

ABOUT DRY EYE DISEASE

DRY EYE DISEASE IS ONE OF THE MOST FREQUENT REASONS THAT PATIENTS VISIT EYE DOCTORS. TO HELP US UNDERSTAND YOUR CONDITION BETTER, EXPLAIN TO US HOW OFTEN YOU EXPERIENCE THE SYMPTOMS BELOW.
Eye Dryness, Grittiness, or Scratchiness *
NeverSometimesOftenConstant
Soreness or Irritation *
NeverSometimesOftenConstant
Burning or Watering *
NeverSometimesOftenConstant

NOW PLEASE TELL IS THE SEVERITY OF YOUR SYMPTOMS.

Instructions Untitled Document
Tolerable – not perfect but not uncomfortable

Bothersome – irritating and interferes with my day

Uncomfortable – irritating but does not interfere with my day

Intolerable – unable to perform my daily tasks
Eye Dryness, Grittiness, or Scratchiness *
No ProblemTolerableUncomfortableBothersomeIntolerable
Soreness or Irritation *
No ProblemsTolerableUncomfortableBothersomeIntolerable
Burning or Watering *
No ProblemsTolerableUncomfortableBothersomeIntolerable
Please select when you last experienced symptoms. *
TodayWithin Past 72 HoursWithin Past 3 Months
Have you ever been told that you have blepharitis or been treated for a stye? *
NoYes - BlepharitisYes - StyeYes - Both
Do you use eye drops and/or ointment? *
YesNo
If yes, which drops or ointment do you use?

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Middletown Eyecare
13324 Shelbyville Rd.
Middletown KY 40223
Call us: 502.245.0305
Fax: 502.254.1425

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ilux

HOURS

Monday 8am-4:30pm
Tuesday 8am-4:30pm
Wednesday 8am-4:30pm
Thursday 8am-4:30pm
Friday 8am-12:30pm

Optical shop is by appointment only with the following hours:

Monday 8am-4:30pm
Tuesday 8am-4:30pm
Wednesday 8am-4:30pm
Thursday 8am-4:30pm
Friday 8am-12:30pm

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13324 Shelbyville Rd.
Middletown KY 40223
Call us: 502.245.0305
Fax: 502.254.1425

Cataracts
LASIK
EVO ICL
Glaucoma
Diabetic Eye Care
Macular Degeneration
Premium Optical Services
Routine Eye Exams
FAQ's
Dry Eye Self Test
ilux

HOURS

Monday 8am-4:30pm
Tuesday 8am-4:30pm
Wednesday 8am-4:30pm
Thursday 8am-4:30pm
Friday 8am-12:30pm

Optical shop is by appointment only with the following hours:

Monday 8am-4:30pm
Tuesday 8am-4:30pm
Wednesday 8am-4:30pm
Thursday 8am-4:30pm
Friday 8am-12:30pm

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