Take the Dry Eye Self Test

Patient Name or ID Date:
Technician

Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease?

Y N When?

Do you have any of the following symptoms?

Blurry vision Tired eyes, eye fatigue
Redness Stringy mucus in or around the eyes
Burning Foreign body sensation
Itching Contact lens discomfort
Light sensitivity Scratchy feeling of sand or grit in the eye
Excess tearing/ watering eyes  

Have you had any of the following surgeries?

Cataract: Y N
Glaucoma: Y N
Refractive Surgery: Y N

Do you use?

Are your symptoms related to the following environmental conditions?

Are you taking any of the following medications?

Have you ever had punctal occlusion? Y N

If the information provided in this form, in conjunction with other clinical data, raises the suspicion of
Dry Eye Disease, then obtaining a Tear Osmolarity Test may be indicated.
I reviewed this form and based on the information contained therein and other available clinical data,
I suspect that this patient has dry eye disease and obtaining a tear osmolarity measurement is
medically necessary for the diagnosis and management of this patient's ocular problem(s).

Attending clinician: Date:

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Set up Your Personal Account

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Set up your Personal Account

SCHEDULE AND APPOINTMENT

Schedule and Appointment

From here you can schedule an appointment, pay a bill, get test results, request a medication refill and much, much more. Click here to login or start a new account

Schedule and Appointment

MEET OUR DOCTORS

Meet Our Doctors

Dr .Wolff has been providing the Northern Nevada region quality eye care for nearly 15 years. He has performed thousands of ocular procedures to the people of our region. Dr Wolff is accepting new patients. Click here to schedule your appointment.

Meet Our Doctors

ADDITIONAL SERVICES

ADDITIONAL SERVICES

Sierra Eye Center is pleased to offer many services online !  Click the link below to access your personal account.

ADDITIONAL SERVICES



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