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McMonnies Dry Eye Questionnaire
Please answer the questions below
Sex:
*
Male
Female
Age:
*
less than 25 years
25-45 years
More than 45 years
Currently wearing:
*
no contact lenses
hard contact lenses
soft contact lenses
Have you ever had drops prescribed or other treatment for dry eye?:
*
Yes
No
Uncertain
Do you ever experience any of the following eye symptoms?:
*
Soreness
Scratchiness
Dryness
Grittiness
Burning
None of the above
How often do your eyes have these symptoms?:
*
Never
Sometimes
Often
Constantly
Are your eyes unusually sensitive to cigarette smoke, smog, air conditioning or central heating?:
*
Yes
No
Sometimes
Do your eyes become very red and irritated when swimming?:
*
Not applicable
Yes
No
Sometimes
Are your eyes dry and irritated the day after drinking alcohol?:
*
Not applicable
Yes
No
Sometimes
Current medication:
Do you take?:
Antihistamine tablets
Antihistamine eye drops
Diuretics (fluid tablets)
Sleeping tablets
Tranquillisers
Oral contraceptives
Medication for duodenal ulcer
Medication for digestive problems
Medication for blood pressure
Antidepressants
Please record any unlisted medication below:
Do you suffer from arthritis?:
*
Yes
No
Uncertain
Do you experience dryness of the mouth, nose, throat, chest or vagina?:
*
Never
Sometimes
Often
Constantly
Do you ever suffer from thyroid abnormality?:
*
Yes
No
Uncertain
Are you known to sleep with your eyes partly open?:
*
Yes
No
Sometimes
Uncertain
Do you have eye irritation as you wake from sleep?:
*
Yes
No
Sometimes
Email:
*
Further information:
If you would like to provide any further information or have any questions please enter them above. This window can be resized.
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