Dry Eye Evaluation Intake Form


Dry eye is much more than just “dryness,” or an insufficient production of tears. It is a very complex condition determined by the combination of multiple underlying issues affecting the tear film composition and ocular surface. Without taking the time and attention to determine the real cause, doctors and patients resort to a trial and error approach.

At your Dry Eye Evaluation we will do a comprehensive examination of everything that might affect the quality and quantity of your tears. We will work to determine what is truly causing your symptoms, and create a plan together to change the environment and stabilize your symptoms. The exam will be focused and you will be told a lot of information. The key is to not panic, trust that everything will be written down, and trust the plan. Dry eye success requires dedication to the treatment course. Though there is no cure for dry eye, if you commit to the treatment plan, you will experience success!

Please download the file and fill out to the best of your ability, either print and bring to your Dry Eye Evaluation or email it to us at Info@bethanyoptical.com

If you cannot finish the intake form before your appointment, please arrive 15 minutes before your exam.


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Bethany Optical
15320 NW Central Drive
Suite D-8
Portland, OR 97229
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Phone: 503-430-0386
Fax: 503-641-2515
info@bethanyoptical.com
Hours
Mon-Thu 9AM - 5PM
Fri 9AM - 4PM