Eyelid Condition Evaluation Form
Please complete this form to help us assess your eyelid condition prior to your consultation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following eyelid symptoms? (Select all that apply)
*
Swelling
Redness
Drooping (Ptosis)
Twitching
Pain or Discomfort
Itching
Other
Please rate the severity of your eyelid symptoms over the past week.
*
Rows
None
Mild
Moderate
Severe
Swelling
1
2
3
4
Redness
5
6
7
8
Drooping (Ptosis)
9
10
11
12
Twitching
13
14
15
16
Pain/Discomfort
17
18
19
20
Itching
21
22
23
24
When did your eyelid symptoms first begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have a history of any of the following?
*
Eye surgery
Eye trauma
Chronic eye diseases (e.g., dry eye, blepharitis)
None of the above
Other
Please upload a clear photo of your affected eyelid(s), if possible.
Upload a File
Drag and drop files here
Choose a file
Cancel
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Are your symptoms getting worse, improving, or staying the same?
*
Getting worse
Improving
Staying the same
Is there anything else you would like us to know about your eyelid condition?
Submit Evaluation
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