Full Name*

Email Address*

Do You ever experience any of these eye-related symptoms?
Dryness, Burning, Tearing, Redness, Itching, Fatique, Scratchy or Gritty Sensation, Itching

If YES please answer the following five questions and rate your symptoms based on a scale of 0-4
0 = Never
1 = Seasonally
2 = Sometimes
3 = Often
4 = Constantly

1. My eyes are Dry, Gritty and Scratchy*

2. My eyes are sore and irritated*

3. My eyes burn or water*

4. I experience eye fatigue*

5. My eyes are red*

Are you interested in contact lenses?*

YES
NO

Do you currently wear contact lenses?*

YES
NO

Are they comfortable?*

YES
NO
N/A

What do you wish was better about your contact lenses?*

Complete Eye Exam Pre-Appointment Steps:

STEP 1 : Dry Eye Questionnaire