Dry & Watery Eyes Service Questionnaire

Please answer the questions below, at the end you will have the option to send your questionnaire directly to your local branch or to print it out to take into your local branch.

1. Have you ever had any treatment for dry eyes in the past?

Yes
No
Sometimes

2. Do you ever experience any of the following symptoms?

Soreness
Scratchiness
Dryness
Grittiness
Burning

3. How often do your eyes have these symptoms?

Never
Sometimes
Often
Constantly

4. Are your eyes usually sensitive to cigarette smoke, smog, air conditioning, or central heating?

Yes
No
Sometimes

5. Do your eyes become very red and irritated when swimming?

Not Applicable
Yes
No
Sometimes

6. Are your eyes dry and irritated the day after drinking alcohol?

Not Applicable
Yes
No
Sometimes

7. Do you take:

Antihistamine tablets
Antihistamine eye drops
Oral contraceptive
Diuretics (tablets for fluid retention)

8. Do you suffer from arthritis?

Yes
No
Uncertain

9. Do you experience dryness of the nose, mouth, throat or chest?

Never
Sometimes
Often
Constantly

10. Do you suffer from thyroid abnormality?

Yes
No
Uncertain

11. Are you known to sleep with your eyes partly open?

Yes
No
Sometimes

12. Do you have eye irritation as you wake from sleep?

Yes
No
Sometimes

13. Gender and age group

Male or Female under 25
Male 25-45
Female 25-45
Male over 45
Female over 45