Dry Eye Questionnaire
1. Questions about EYE DISCOMFORT:
a. During a typical day in the past month, how often did your eyes feel discomfort?
b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of
the day, within two hours of going to bed?
2. Question about EYE DRYNESS:
a. During a typical day in the past month, how often did your eyes feel dry?
b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day
within two hours of going to bed?
3. Question about WATERY EYES:
During a typical day, in the past month, how often did your eyes look or feel excessively
watery?
Submit Data, Policies, Consents
CONSENTS & INFORMATION
PATIENT CONTACT LENS INFORMED CONSENT AND CONTACT LENS REGIMEN FORM
Click here for full Contact Lens Consent
Click here for
Spanish Contact Lens Consent and testing info
I UNDERSTAND THAT THE FDA (THE UNITED STATES FOOD AND DRUG ADMINISTRATION) REGULATES CONTACT
LENSES (CONTACTS), GIVEN THAT THEY ARE CONSIDERED MEDICAL DEVICES.
WARNING:
KERATITIS, OR INFLAMMATION OF THE CORNEA, IS ONE OF THE MOST SEVERE COMPLICATIONS OF THE OCULAR SURFACE
THAT CAN LEAD TO SCARRING THE CORNEA AND/OR
SIGNIFICANT OR COMPLETE VISION LOSS. ONE CAUSE OF KERATITIS IS SECONDARY TO CONTACT LENS WEAR.
CONTRIBUTING FACTORS ALSO INCLUDE, BUT NOT LIMITED TO; SMOKING,
PREVIOUS EYE INJURIES, PREVIOUS EYE SURFACE CONDITIONS, TRAUMA, POOR HYGIENE OR LENS CARE, CONTACT LENS
OVERWEAR, AND/OR CONTACT LENS PRODUCTS. HOWEVER, SLEEPING IN YOUR
CONTACTS, POSES THE GREATEST RISK FOR COMPLICATIONS.
ADDITIONAL INFORMATION CAN BE FOUND ON THE FOOD AND DRUG ADMINISTRATION WEB SITE
I UNDERSTAND THAT THERE ARE BOTH BENEFITS AND RISKS TO WEARING CONTACT LENSES. THE BENEFITS INCLUDE
IMPROVED VISION, COSMETIC APPEAL, AND/OR CONVENIENCE.
I UNDERSTAND THAT PROPER USAGE AND CARE OF MY CONTACT LENSES, LENS CARE PRODUCTS, AND LENS CASES ARE
CRITICAL TO SAFE WEAR OF CONTACT LENSES.
I UNDERSTAND THAT SERIOUS DAMAGE TO THE EYE, SCARRING OF THE CORNEA, AND VISION LOSS CAN RESULT FROM
PROBLEMS ASSOCIATED WITH WEARING CONTACT LENSES,
IMPROPER LENS CARE HABITS, AND UTILIZING LENS CARE PRODUCTS.
PROPER CARE FOR MY CONTACT LENSES INCLUDE, BUT IS NOT LIMITED TO, PROPER CONTACT LENS AND CONTACT
LENS CASE CARE, ADHERING TO MY WEARING SCHEDULE, REPLACEMENT SCHEDULE, RECOMMENDED SOLUTIONS AND
PRODUCTS, AND PRESENTING MY FOLLOW-UP APPOINTMENTS AND YEARLY EYE EXAMINATIONS. I UNDERSTAND THAT
FAILURE TO COMPLY WITH THE PREVIOUS STATEMENTS COULD RESULT IN DAMAGING MY EYES AND/OR IN
TERMINATION OF CONTACT LENS WEAR BY THIS OFFICE.
I UNDERSTAND THAT IT IS POSSIBLE FOR PROBLEMS, INCLUDING CORNEAL ULCERS, TO RAPIDLY DEVELOP AND LEAD
TO VISION LOSS. I UNDERSTAND THAT IF I EXPERIENCE ANY EYE DISCOMFORT, SENSITIVITY TO LIGHT,
BURNING, ITCHING, EXCESSIVE TEARING, REDNESS, DECREASED VISION, PAIN, DRYNESS, UNCOMFORTABLE
LENS SENSATION, OR ANY UNUSUAL EYE SECRETIONS AND SYMPTOMS TO IMMEDIATELY REMOVE MY
CONTACT LENSES AND PROMPTLY CONTACT THIS OFFICE AT 434.973.7996
IMPORTANT:
REGARDLESS OF WHERE YOU PURCHASE CONTACTS; YOUR WEARING SCHEDULE, SOLUTION, REPLACEMENT SCHEDULE, CARE
REGIMEN, FOLLOW-UP & EXAMS REMAIN THE SAME.
I FULLY UNDERSTAND THE RISKS AND BENEFITS OF WEARING CONTACT LENSES. I AGREE TO RETURN FOR MY FOLLOW-UP
VISIT WHOSE MAIN PURPOSE IS TO ENSURE THE SAFETY OF MY EYES. BY SIGNING
THIS CONSENT I AGREE TO ADHERE TO THE CONTACT LENS INSTRUCTIONS AS STATED ABOVE.
Patient Signature:
Date:
HEALTH CARE SERVICES:
Click here to view our Policy's (English)
Click here to view our Policy's (Spanish)
MINORS:
I give permission for my child to have any diagnostic drops or
contact lens service which may be required for an eye
exam or contact lens fitting.
FINANCIAL/INSURANCE:
Dilation
Yes, I,
, understand the side effects and benefits of dilation and hereby authorize administering the dilating eye drops
No, I,
, understand that I am opting against what is recommended for my comprehensive ocular health by the optometrist.
Retinal Photograph:
Acquires a digital image of the back of the eye to allow the optometrist to look for diseases and track
changes over time.
I
will have an OPTOMAP (retinal photo) taken today for a co-pay of
$29.00
I understand that I am opting
against what is recommended for my ocular health by the optometrist
I acknowledge that I have read this form and understand its content. I am the patient or the person duly authorized either by the patient or
otherwise, sign this agreement, consent to, and accept its terms. I am responsible for the payment and/or co-payment that is due at the time
of service, and I have been given the option for a copy of the CLE HIPPA Policy
Patient (or person authorized to sign for patient)
Specialty Testing
Click here for Special Testing info
Click here for Spanish Special Testing info
LipiScan:
Yes I do want the LipiScan($30).
No, I do NOT want the LipiScan.
Tear Osmolarity:
Yes I do want the Tear Osmolarity($30).
No, I do NOT want the Tear Osmolarity.
InflammaDry:
Yes I do want the InflammaDry($30).
No, I do NOT want the InflammaDry.