Dry Eye Testing Protocol Checklist

Dry Eye Testing Protocol Checklist

This protocol has been designed to determine when InflammaDry testing is medically necessary. All patients that meet the designed protocol are considered to be at risk for Dry Eye Disease and should be tested.

1. Check the box next to the symptoms you are experiencing: Fluctuating Vision Redness Burning Itching Light sensitivity Excess tearing/watering Tired eyes, fatigue Stringy, mucous in or around the eye Foreign body sensation Contact lens discomfort Scratchy/gritty feeling in the eye Excessive tearing

2. Do you use 1 or more of the following: OTC drops (such as artificial tears) Rx eye drops for dry eye disease (eg. Restasis, Xiidra) Rx drops for glaucoma (eg. Xalatan, Timolol) Rx eye drops for allergy (Anti-inflammatory, antihistamine)

3. Are you considering any of the following surgeries: Cataract surgery Refractive surgery Glaucoma surgery

4. Have you tested positive in a previous visit and are returning for repeat evaluation after treatment? Yes No

Note: If you refuse the testing from the above protocol it must be documented in your chart.

TC1024001EN00 (11/18)

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