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Just North of Horsetooth on Shields St. in Fort Collins, CO

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Home » TearScience LipiFlow » Dry Eye Form

Dry Eye Form

Please take a few minutes to complete the questionnaire below.

Dry Eye Form

Name*
First Last
Age
Email
Best phone number to reach you
Symptom Frequency - Describe the FREQUENCY of dry eye symptoms you are experiencing by selecting Never, Sometimes, Often or Constant below:
Dryness, Grittiness or Scratchiness
- Constant
- Often
- Sometimes
- Never
Soreness or Irritation
- Constant
- Often
- Sometimes
- Never
Burning or Watering
- Constant
- Often
- Sometimes
- Never
Eye Fatigue
- Constant
- Often
- Sometimes
- Never
Please indicate how recently you have experienced symptoms:
- Today
- Within the past 72 hours
- Within the past 3 months
Do you have fluctuating vision problemss that can be corrected with blinking?
- A Lot/Always
- Frequently
- Sometimes
- Never
Symptom Severity - Describe the SEVERITY of your symptoms using the ratings list below:
Dryness, Grittiness or Scratchiness
- Intolerable (unable to perform my daily tasks)
- Bothersome (irritating and interferes with my day)
- Uncomfortable (irritating but does not interfere with my day)
- Tolerable (not perfect but not uncomfortable)
- No problems
Soreness or Irritation
- Intolerable (unable to perform my daily tasks)
- Bothersome (irritating and interferes with my day)
- Uncomfortable (irritating but does not interfere with my day)
- Tolerable (not perfect but not uncomfortable)
- No problems
Burning or Watering
- Intolerable (unable to perform my daily tasks)
- Bothersome (irritating and interferes with my day)
- Uncomfortable (irritating but does not interfere with my day)
- Tolerable (not perfect but not uncomfortable)
- No problems
Eye Fatigue
- Intolerable (unable to perform my daily tasks)
- Bothersome (irritating and interferes with my day)
- Uncomfortable (irritating but does not interfere with my day)
- Tolerable (not perfect but not uncomfortable)
- No problems
Current Treatment
Do you use eye drops and/or ointment?
- Yes
- No
If YES, which drops do you use?
Have you been told that you have blepharitis?
- Yes
- No
Have you been treated for a stye?
- Yes
- No

Northern Colorado's Dry Eye Specialists

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20/20 Vision Center

Phone: (970) 490-2020
Fax: (970) 221-3121
Email: reception@2020visioncenter.com
(Do not send personal health information by email.)

3501 S. Shields St.
Fort Collins, CO 80526

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Find Us Here

20/20 Vision Center - Located at 3501 S Shields St., Fort Collins, CO, 80526. Phone: 970-490-2020. https://www.2020visioncenter.com/

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