iTEAR100 Prescription Questionnaire

by Olympic Ophthalmics
iTEAR100 Prescription Questionnaire

Fill out this form to request prescription from a company Doctor. Most of information is not required but like any Doctor visit, the more you provide, the easier it is for the company to determine if you will benefit from iTEAR treatment. If you are not comfortable submitting name and email then write in your initials and send us an email or fax with rest of information. You can also print this entire form and FAX to 206-984-1564 and/or send to itear100prescription@oo-med.com.
PLEASE NOTE: WE HAVE A PARTNERSHIP WITH EYECARELIVE FOR MANY STATES IN THE U.S. (only); THEY ARE A TELEHEALTH COMPANY WHO MAY CONTACT YOU. THERE IS NOT A CHARGE FOR THEIR SERVICE AT THIS TIME. HOWEVER THEY MAY REQUIRE PHONE NUMBER, BIRTHDAY, AND ADDRESS TO BE FILLED IN AND ALSO MAY REQUIRE A VIDEO CALL. NOT FILLING IN THE ADDRESS AND PHONE NUMBER FIELD MIGHT LEAD TO DELAYS AND/OR REJECTION OF YOUR PRESCRIPTION APPLICATION
INTERNATIONAL PATIENTS MAY NOT NEED A PRESCRIPTION IN THEIR COUNTRY; HOWEVER WE APPLY SAME PROCESS AS IN THE U.S. AND A COMPANY DOCTOR WILL REVIEW THIS QUESTIONNAIRE PRIOR TO ALLOWING A PURCHASE. THIS PROCESS WILL ALLOW THE COMPANY TO SET EXPECTATIONS AND RECOMMENDATIONS AS FAR AS WHO WE THINK WILL BENEFIT MOST BASED ON OUR EXPERIENCE. INTERNATIONAL PATIENTS ALSO BENEFIT FROM HAVING A COMPANY DOCTOR IN THS U.S. TO ASSESS THEIR PROGRESS AND TRAIN IF NEEDED.
**PRESCRIPTION IS NOT GUARANTEED FOR FILLING OUT THIS INFORMATION
Date submitted

MonthDayYear
Date
Name (Leave at least initials)*

First NameLast Name
Why are you filling out this form*
If Clinical Trial Please also fill out information at itear100.com/ilids
Email *
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Country (required)*
State (required)*
How long have you had problems with your eyes which may be diagnosed as dry eye (enter number for years)?

	Yes	No
Have you been diagnosed with dry eye?
Do you wear contact lenses?
Have you had LASIK surgery or other procedures on your eyes?
Do you wear eye makeup?
Do you have increased intraocular pressure or glaucoma?
Do you see an eyecare specialist with dry eye expertise?
Do you take medications known to cause dry eye such as anti-histamines, anti-depressants, anti-hypertensive, etc.?
Do you have a history of headaches or migraine?
Do you have a history or blepharitis (eyelid inflammation)
Do you have a history of trigeminal or herpetic neuralgia

What is your worst symptom?
What is your age? *
Birthdate

MonthDayYear
Date
What is your ethnicity? (optional)
Biolgic Gender*

MF
How many hours do you spend in front of the computer each day?
Does computer work make your symptoms worse?

YesNo

Have you tried or currently using any of the following?

	Yes Tried	No	Still Use
iTear 100
True Tear (intranasal neurostimulation)
Oxervate
Tyrvaya
Restasis
Xiidra
IPL
Lipiflow
Meibomian Gland Expression (with IPL or alone)
Tearcare
Cequa
Nulids
Bruder Mask
Regener-eyes
Klarity-C
Serum tears (From your own blood)
over the counter artificial tears

If currently use artificial tears, how many times per day
List your current treatment regimen for symptoms if not indicated above? (include prescription and over the counter medications, vitamins, devices, etc)
Have you had a Schirmer test
Have you had a Schirmer test

yesnoOther
If yes, what was score (if don't remember number and only remember Doctor comment [e.g. low, normal], then write in comment)
Have you had any meibomian gland testing
Do you remember any results from or name of this testing?
SPEED SURVEY
Report the type of SYMPTOMS you experience and when they occur:

Have you experienced the following symptoms today ?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Have you experienced the following symptoms WITHIN THE PAST 72 HOURS?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Have you experienced the following symptoms WITHIN THE PAST 3 MONTHS?

	YES	NO
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Report the FREQUENCY of the following symptoms as Never, Sometimes, Often or Constant using the numbering system below:

FREQUENCY of the following symptoms

	0-Never	1-Sometimes	2-Often	3-Constant
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Total score of Frequency (add rows)
Report the SEVERITY of your symptoms using the rating list below:

SEVERITY of symptoms

	0-No Problem	1- Tolerable, not perfect but not uncomfortable	2-Uncomfortable, irritating but does not interfere with my day	3-Bothersome, irritating & interferes with my day	4 - Intolerable, unable to preform my daily tasks
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Total score of Severity (add rows)
Total SPEED Score (add severity and frequency)
Do you use over the counter tears?

YesNo
Any Other Medical history or Medications Which Might Cause Your Symptoms
What insurance do you have? (not required)
How did you hear about iTEAR100
Technical Ability (1-4) iTEAR100 requires an app for activation and other functions. We offer ability to bypass the app but only recommend this option for patients who cannot use phone applications.

4 Use apps on a daily basis3 Occasionally use apps2 Struggle with apps and avoid at all costs1 Do not have a smart phone
Signature*

Clear
Should be Empty:

by Olympic Ophthalmics

iTEAR100 Prescription Questionnaire

SPEED SURVEY