Dry Eye Risk Assessment Take our online risk assessment to find out if you may have Dry Eye Syndrome. Your results will be sent to us for evaluation and someone will contact you to discuss your results if an evaluation is recommended. A printable version of our quiz is available in Adobe PDF format: Click to download. Name: Email: Home Phone: Work Phone: Cell Phone: Address: Age: Employer: How do you prefer to be contacted? Select Contact Preference Home Phone Work Phone Cell Phone Email How often do you have these problems? Redness never rarely commonly always   Sandy-gritty feeling never rarely commonly always   Itching never rarely commonly always   Excess watering never rarely commonly always   Burning never rarely commonly always   Excess mucous never rarely commonly always   Blurry Vision helped by blinking never rarely commonly always   Are your eyes sensative to these conditions? Smoke never rarely commonly always   Light never rarely commonly always   Air Pollution never rarely commonly always   Wind never rarely commonly always   Computer Screens never rarely commonly always   Heaters never rarely commonly always   Air Conditioning never rarely commonly always   Contact Lenses never rarely commonly always   Have you been diagnosed with any of these conditions? Thyroid Abnormality    No Yes   Rheumatoid Arthritis    No Yes   Asthma    No Yes   Diabetes    No Yes   Glaucoma    No Yes Lupus    No Yes Rosacea    No Yes Do you experience contact lens discomfort?    No Yes Are you post menopausal?    No Yes Do you get eye strain?    No Yes Do you blink your eyes excessively?    No Yes