Dry Eye Intake Form – Comprehensive & Patient-Friendly Evaluation Tool 🌿👁️
Grow your dry eye clinic with this specialized intake form designed specifically for dry eye evaluations. Perfect for follow-up visits after routine exams, this form helps patients come prepared—and gives you the detailed insights needed to deliver personalized, effective care.
Hand it out when scheduling dry eye consultations to streamline your workflow and ensure no key details are missed.
Form includes:
✔️ Symptom review with built-in SPEED questionnaire
✔️ Lifestyle and makeup habits
✔️ Contact lens and ocular health history
✔️ Relevant systemic and medical background
✔️ Environmental factors at work and home
✔️ Previous treatments and outcomes
✔️ Patient goals and expectations
Carefully structured to reveal common triggers and overlooked contributors to dry eye, this form supports stronger treatment planning and long-term care strategies.
Perfect for:
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Expanding your dry eye specialty services
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Standardizing documentation across visits
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Improving exam efficiency and follow-up care
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Supporting personalized treatment plans
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Empowering patients to share relevant history
A must-have tool for any practice committed to delivering high-quality dry eye care.
Size: US Letter Portrait (8.5 x 11 in), printed on 24 lb laser paper (90 gsm)
Listing price covers cost for printed documents, shipping, and customization (adding office logo and necessary information and altering colors to match branding).
Want to save some trees? Check out the fillable PDF version of this intake form instead!
Special Notes: Please attach logo prior to purchasing!
