iTEAR100 Prescription Questionnaire

by Olympic Ophthalmics
iTEAR100 Prescription Questionnaire

Fill out this form to request prescription from a company Doctor. Most of information is not required but like any Doctor visit, the more you provide, the easier it is for the company to determine if you will benefit from iTEAR treatment. If you are not comfortable submitting name and email then write in your initials and send us an email or fax with rest of information. You can also print this entire form and FAX to 206-984-1564 and/or send to itear100prescription@oo-med.com.
Date submitted

MonthDayYear
Date
Name (Leave at least initials)*

First NameLast Name
Why are you filling out this form*
Email *
example@example.com
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country (required)*
State (required)*
How long have you had problems with your eyes which may be diagnosed as dry eye (enter number for years)?

	Yes	No
Have you been diagnosed with dry eye?
Do you wear contact lenses?
Have you had LASIK surgery or other procedures on your eyes?
Do you wear eye makeup?
Do you have increased intraocular pressure or glaucoma?
Do you see an eyecare specialist with dry eye expertise?
Do you take medications known to cause dry eye such as anti-histamines, anti-depressants, anti-hypertensive, etc.?
Do you have a history of headaches or migraine?

Have you tried or currently using any of the following?

	Yes Tried	No	Still Use
iTear 100
True Tear
Oxervate
Tyrvaya
Restasis
Xiidra
IPL
Lipiflow
Meibomian Gland Expression (with IPL or alone)
Tearcare
Cequa
Nulids
Bruder Mask
Regener-eyes
Klarity-C
Serum tears
over the counter artificial tears

List your current treatment regimen for symptoms if not indicated above? (include prescription and over the counter medications, vitamins, devices, etc)
Have you had a Schirmer test
Have you had a Schirmer test

yesnoOther
If yes, what was score (if don't remember number and only remember Doctor comment [e.g. low, normal], then write in comment)
Have you had any meibomian gland testing
Do you remember any results from or name of this testing?
SPEED SURVEY
Report the type of SYMPTOMS you experience and when they occur:

Have you experienced the following symptoms today ?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Have you experienced the following symptoms WITHIN THE PAST 72 HOURS?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Have you experienced the following symptoms WITHIN THE PAST 3 MONTHS?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Report the FREQUENCY of the following symptoms as Never, Sometimes, Often or Constant using the numbering system below:

FREQUENCY of the following symptoms

	0-Never	1-Sometimes	2-Often	3-Constant
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

SEVERITY of symptoms

	0-No Problem	1- Tolerable, not perfect but not uncomfortable	2-Uncomfortable, irritating but does not interfere with my day	3-Bothersome, irritating & interferes with my day	4 - Intolerable, unable to preform my daily tasks
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

SPEED SURVEY