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Home » Eye Care Services » Dry Eye » Dry Eye Questionnaire

Dry Eye Questionnaire

Please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

1. Do you experience EYE DISCOMFORT?

a. During a typical day in the past month, how often did your eyes feel discomfort?(Required)

Never

Rarely

Sometimes

Frequently

Constantly

b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?(Required)

None

Mild

Moderate

Severe

Very Severe

2. Do you experience EYE DRYNESS?

a. During a typical day in the past month, how often did your eyes feel dry?(Required)

Never

Rarely

Sometimes

Frequently

Constantly

b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?(Required)

None

Mild

Moderate

Severe

Very Severe

3. Do you have WATERY EYES?

During a typical day in the past month, how often did your eyes look or feel excessively watery?(Required)

Never

Rarely

Sometimes

Frequently

Constantly

Score

Would you like for us to review your score with you?(Required)

Yes

No

Please enter your contact information below, and one of our team members will reach out to you to discuss your dry eye score.

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Premier Eye Associates

571 Haddon Ave
Collingswood, NJ 08108

Phone: 856-858-3937
Email: info@premiereyedoctors.com
(Do not send personal health information by email.)

Monday: 10:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 9:00 AM - 7:00 PM
Friday: 9:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Premier Eye Associates

701 Route 73 North, Suite 33
Marlton, NJ 08053

Phone: 856-988-1118

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Home
Contact Us
What’s New
Disclaimer
Privacy Policy
HIPAA Official Notice of Privacy Practices
Your Rights and Protections Against Surprise Medical Bills

PREMIER EYE ASSOCIATES

At Premier Eye Associates, our optometry staff works together to ensure your visit is comfortable and completed in a timely manner. We have a qualified team of professionals that will work around your busy schedule and address any questions or concerns prior to the appointment.

OFFICE HOURS

Monday: 10:00am – 5:00pm
Tuesday: 9:00am – 5:00pm
Wednesday: 10:00am – 6:00pm
Thursday: 9:00am – 7:00pm
Friday: 9:00am – 5:00pm
Saturday: Closed
Sunday: Closed

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Premier Eye Associates - Located at 701 Route 73 North, Suite 33, Marlton, NJ , 08053. Phone: 856-988-1118 . https://www.premiereyedoctors.com

Premier Eye Associates - Located at 571 Haddon Ave, Collingswood, NJ , 08108. Phone: 856-858-3937 . https://www.premiereyedoctors.com

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