Dry Eye Evaluation Form

Filling out the Speed Questionnaire and submitting to our office will help us determine how the Southern Eye Group Dry Eye Clinic can be of most help to you.

*This is a required field






Report the Frequency of your symptoms by checking the appropriate box.

0 = Never
1 = Sometimes
2 = Often
3 = Constant





Report the Severity of your symptoms using the rating list below.

0 = No Problems
1 = Tolerable - not perfect, but not uncomfortable
2 = Uncomfortable - irritating, but does not interfere with my day
3 = Bothersome - irritating and interferes with my day
4 = Intolerable - unable to perform daily tasks












 

Call 251-990-3937 and schedule a Dry Eye Consultation today
or book an appointment online.

COVID-19 UPDATE
We are OPEN to continue to provide the highest quality eye care to our patients. In accordance with CDC guidelines, we are limiting the number of patients in our practice at any one time through virtual waiting rooms, limiting 1 guest per patient and also following strict hygiene protocols. In the abundance of caution for our patients, staff, and doctors we ask if you are experiencing any of the following symptoms that you call our office to reschedule your appointment: cough, fever, chills, or sore throat.

We are now offering telemedicine appointments for qualifying visit types. Please call us for our doctors' to determine if this would apply to you. Telemedicine visits are currently covered by the following insurances: Medicare, Medicaid, Blue Cross Blue Shield, Aetna, Cigna, HealthSpring, Tricare and United Health Care.

As always, we are here to help in any way that we can.

Please contact our office at 251-990-3937 for more information.