Dry Eye Treatment Plan Form
Use this form to share information about your dry eye symptoms, history, and treatment preferences so a treatment plan can be prepared.
Patient Details
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text
Dry Eye Symptoms and History
Main Symptoms
*
Dryness
Burning
Stinging
Grittiness
Blurred Vision
Watering
Redness
Other
Symptom Severity
*
Mild
Moderate
Severe
How Long Symptoms Have Been Present
Known Triggers or Worsening Factors
Screen time
Contact lenses
Dry environments
Wind
Air conditioning
Reading
Driving
Allergies
Other
Past Eye Treatments Tried
Artificial tears
Warm compresses
Lid hygiene
Prescription eye drops
Omega-3 supplements
Punctal plugs
Contact lens changes
Other
Treatment Planning Preferences
Current eye drops or other treatments
Artificial tears
Prescription eye drops
Warm compresses
Lid hygiene
Omega-3 supplements
Other
Do you use contact lenses?
*
Yes
No
Occasionally
Preferred treatment goals or notes for the clinician
Submit
Should be Empty: