Innovative Research Oculus Research Garner, North Carolina Dry Eye Dry Eye Pre-Screening Questionnaire Are you 18 years of age or older?(Required) Yes No Date of Birth(Required)Have you been diagnosed by a doctor with Dry Eye?(Required) Yes No Not sure How would you rate your symptoms related to Dry Eye Disease? (0=none, 10=most severe)(Required) None (0) Mild (1-4) Moderate (5-7) Severe (8-10) Have you used any over-the-counter treatments related to Dry Eye Disease within the last 30 days?(Required) Yes No Please Specify(Required)Have you used any nasal, inhaled, systemic (including injections), or topical corticosteroids within 30 days? (Example: Flonase, fluticasone, etc.)(Required) Yes No Please Specify(Required)Have you used any products or therapies within the timeframes listed below, including the following? Contact lenses (within the last 14 days) Ocular prescription medications (within the last 30 days) Mechanical dry eye treatments (within the last 30 days) (e.g., LipiFlow®, BlephEx®, intense pulsed light (IPL), or similar in-office procedures)(Required) Yes No Not Sure Please Specify item(s) and date(s) of last use:(Required)Please Specify(Required)Have you had any eye procedures, surgeries, or injections within the last 6 to 12 months? (Including, but not limited to: LASIK, refractive surgery, cataract surgery, etc.)(Required) Yes No Please Specify When(Required)Have all medications (both over-the counter and prescription) been stable for at least 30 days?(Required) Yes No Please Specify(Required)Do you have any significant or uncontrolled medical conditions that could affect study participation or safety?(Required) Yes No Not sure Please Specify(Required)Please Specify(Required)Your Name(Required) First Last Your Email Address(Required) Email Address Confirm Email Address Your Phone(Required)CAPTCHA
