Patient Information › Symptoms Checklist

Symptoms Checklist by Language:
Download a free Acrobat Reader Adobe Acrobat here (12.5 - 20 MB, for .pdf files)

PLEASE NOTE: To ensure a proper Eye Health Examination indicate symptoms or conditions you now experience, or have experienced during the last 12 months. Provide complete answers.
Name:
Date:
EYE SYMPTOMS Right Eye Left Eye
  YES YES
Redness
Dry Eye Feeling
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Constant Tearing
Occasional Tearing
Watery Eyes
Light Sensitivity
Eye Pain or Soreness
Sties, Chalazion
Fluctuating Visual Acuity
“Tired” Eyes
Contact Lens Discomfort
Contact Lens Solution Sensitivity
Mucous Discharge
SECONDARY SYMPTOMS  
  YES
Sinus Problems
Nasal Congestion
Head Congestion
Post-nasal Drip
Chronic Bronchitis
Allergy Symptoms
Hay Fever
Chronic Cold Symptoms
Middle Ear Congestion
Sneezing
Dry Mouth or Throat
Headaches
Asthma Symptoms
Heartburn or Indigestion
Snoring
Sleep Apnea
GERD
   
Check items which you are sensitive to:  
       
Heaters Dust
Blowers Pollen
Air Conditioning Airplane Cabins
Cigarette Smoke Computer Screens
Smog Sunshine
Contact Lens Wear Wind
Check conditions you or a family member
(blood relative) have experienced:
Glaucoma Diabetes
Tuberculosis Rheumatoid
Lupus Thyroid Disorder
Gout Heart Disease
Cataracts High Blood Pressure
Arthritis Sjogren’s Syndrome
   
Do you use lubricating drops? What brand?
Do you wear contact lenses How often?
Are your contacts comfortable? How long have you worn them?
Have you tried contacts before and quit? Why?
Do you use glasses? How long have you had them?
Have you ever had an eye injury? Describe the injury:
Are you allergic to anything? List:
Do you take any medications? List:
Additional comments:    
Patient’s Signature:
Doctor’s Name:  
Date:
7195 Rev C

(800) 367-8327
9 Hope Lane, P.O. Box 1209, Eastsound, WA 98245 • USA
Tel: (360) 376-7095 • Fax: (360) 376-7085

Home | Physician Information | Occlusion Therapy | Patient Information | Company | Find | Contact | Site Map

© 2005, 2006 Lacrimedics, Inc.
Herrick Lacrimal Plug™, Herrick System™, Lacrimal Efficiency Test™ and the Lacrimedics eye logo are trademarks of Lacrimedics, Inc.

Website by DoubleRich Design