Answer the following questions and submit your quiz. A member of the Williamson Eye Center will review your answers promptly.

Name:   Email:   Telephone:   How would you like to be contacted?   Tel    Email

How often do you have these problems?     Never Rarely Commonly Always A.   Redness                 B.   Sandy / Gritty Feeling                 C.   Itching                 D.   Excess Watering                 E.   Burning                 F.   Excess Mucous                 G.   Blurry Vision (helped by blinking)

Are your eyes sensitive to these conditions?     Never Rarely Commonly Always A.   Smoke                 B.   Light                 C.   Air Pollution                 D.   Wind                 E.   Computer Screens                 F.   Heaters                 G.   Air Conditioning                 H.   Contact Lenses

Do you get eye strain?   No Yes Do you blink your eyes excessively?   No Yes

Note: Other health conditions may contribute to dry eye. In addition many medications can create dry eye symptoms.