Dry Eye Self-Assessment

Dry Eye Disease is the most common reason that patients visit eye doctors. Sometimes our eyes show signs of progressive dry eyes that can worsen over time, even though we don’t realize it.  To find out if you might be suffering with this condition as well, please complete the questionnaire below the best you can. Your information will be kept confidential, and once you submit it please call us at 520-744 1711 an evaluation with Dr. Burgett so we can evaluate your eyes for dryness using sensitive testing instruments.  He will then review your tests with you and recommend any treatment options for the fastest path to lasting relief. By submitting this form, we understand that you agree and consent to be contacted by an AVC staff from Advanced Vision Care concerning your dry eye assessment.

Dry Eye Assessment
Dry Eye Frequency

Report the FREQUENCY of dry eye symptoms you are experiencing as never, sometimes, often or constant using the numbering system below.

Symptom Severity

Report the SEVERITY of your symptoms using the rating list below.

Contact Info

By submitting this form, I agree and consent to being contacted by an optometric technician/representative from Shady Grove Eye and Vision Care concerning the dry eye assessment.