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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?

Verification

Please enter any two digits *Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:

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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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SERVICES

Cataracts
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Premium Optical Services
Routine Eye Exams
FAQ's
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ilux

HOURS

Monday: 8:00am – 5:00pm
Tuesday: 8:00am – 12:00pm
Wednesday: 8:00am – 5:00pm
Thursday: 8:00am – 5:00pm
Friday: 8:00am – 5:00pm

Optical shop is by appointment only with the following hours:
Monday: 8:30am – 5:00pm
Tuesday: 8:30am – 1:00pm
Wednesday: 8:30am – 5:00pm
Thursday: 8:30am – 5:00pm
Friday: 8:30am – 5:00pm

CLOSED

December 23 - Closed PM

December 24 - Closed

December 25 - Closed

December 26 - Closed

Schedule Your Appointment Today!

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

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

HOURS

Monday: 8:00am – 5:00pm
Tuesday: 8:00am – 12:00pm
Wednesday: 8:00am – 5:00pm
Thursday: 8:00am – 5:00pm
Friday: 8:00am – 5:00pm

Optical shop is by appointment only with the following hours:
Monday: 8:30am – 5:00pm
Tuesday: 8:30am – 1:00pm
Wednesday: 8:30am – 5:00pm
Thursday: 8:30am – 5:00pm
Friday: 8:30am – 5:00pm

CLOSED

December 23 - Closed PM

December 24 - Closed

December 25 - Closed

December 26 - Closed

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