{"id":8074,"date":"2021-07-20T16:34:03","date_gmt":"2021-07-20T23:34:03","guid":{"rendered":"https:\/\/www.medicaleyecenter.com\/?page_id=8074"},"modified":"2021-10-22T12:50:09","modified_gmt":"2021-10-22T19:50:09","slug":"self-evaluation","status":"publish","type":"page","link":"https:\/\/www.medicaleyecenter.com\/specialties\/dry-eye\/self-evaluation\/","title":{"rendered":"Dry Eye Self Evaluation"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8074\" class=\"elementor elementor-8074\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0e67390 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0e67390\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7e3ab4b\" data-id=\"7e3ab4b\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8031fe8 elementor-widget elementor-widget-heading\" data-id=\"8031fe8\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">DRY EYE SELF-EVALUATION<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ba3a947 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ba3a947\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b9f6fa3\" data-id=\"b9f6fa3\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-73711ce elementor-widget elementor-widget-html\" data-id=\"73711ce\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<script defer src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/punycode\/1.4.1\/punycode.js\"><\/script>\r\n<script src=\"https:\/\/cdn01.jotfor.ms\/js\/vendor\/jquery-1.8.0.min.js?v=3.3.26544\" type=\"text\/javascript\"><\/script>\r\n<script defer src=\"https:\/\/cdn02.jotfor.ms\/js\/vendor\/maskedinput.min.js?v=3.3.26544\" type=\"text\/javascript\"><\/script>\r\n<script defer src=\"https:\/\/cdn03.jotfor.ms\/js\/vendor\/jquery.maskedinput.min.js?v=3.3.26544\" type=\"text\/javascript\"><\/script>\r\n<script 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href=\"https:\/\/cdn01.jotfor.ms\/themes\/CSS\/5e6b428acc8c4e222d1beb91.css?\"\/>\r\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/css\/styles\/payment\/payment_styles.css?3.3.26544\" \/>\r\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn03.jotfor.ms\/css\/styles\/payment\/payment_feature.css?3.3.26544\" \/>\r\n<form class=\"jotform-form\" action=\"https:\/\/hipaa.jotform.com\/submit\/212007278264048\/\" method=\"post\" name=\"form_212007278264048\" id=\"212007278264048\" accept-charset=\"utf-8\" autocomplete=\"off\">\r\n  <input type=\"hidden\" name=\"formID\" value=\"212007278264048\" \/>\r\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\r\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\r\n  <div role=\"main\" class=\"form-all\">\r\n    <style>\r\n      .form-all:before { background: none;}\r\n    <\/style>\r\n    <ul class=\"form-section page-section\">\r\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\r\n        <div class=\"form-header-group  header-large\">\r\n          <div class=\"header-text httal htvam\">\r\n            <h1 id=\"header_1\" class=\"form-header\" data-component=\"header\">\r\n              Thank you for your interest.\r\n            <\/h1>\r\n            <div id=\"subHeader_1\" class=\"form-subHeader\">\r\n              Dry eye disease is one of the most frequent reasons that patients visit eye doctors. Please complete this dry eye disease self-evaluation to determine if you might be suffering from dry eye.\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_3\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_3\" for=\"first_3\">\r\n          Name\r\n          <span class=\"form-required\">\r\n            *\r\n          <\/span>\r\n        <\/label>\r\n        <div id=\"cid_3\" class=\"form-input-wide jf-required\" data-layout=\"full\">\r\n          <div data-wrapper-react=\"true\">\r\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\r\n              <input type=\"text\" id=\"first_3\" name=\"q3_name[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_3 sublabel_3_first\" required=\"\" \/>\r\n              <label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_3_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\r\n            <\/span>\r\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\r\n              <input type=\"text\" id=\"last_3\" name=\"q3_name[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_3 sublabel_3_last\" required=\"\" \/>\r\n              <label class=\"form-sub-label\" for=\"last_3\" id=\"sublabel_3_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\r\n            <\/span>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_4\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"input_4\">\r\n          Email\r\n          <span class=\"form-required\">\r\n            *\r\n          <\/span>\r\n        <\/label>\r\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\" data-layout=\"half\">\r\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\r\n            <input type=\"email\" id=\"input_4\" name=\"q4_email\" class=\"form-textbox validate[required, Email]\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"email\" aria-labelledby=\"label_4 sublabel_input_4\" required=\"\" \/>\r\n            <label class=\"form-sub-label\" for=\"input_4\" id=\"sublabel_input_4\" style=\"min-height:13px\" aria-hidden=\"false\"> example@example.com <\/label>\r\n          <\/span>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_5\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_5\" for=\"input_5_full\">\r\n          Phone Number\r\n          <span class=\"form-required\">\r\n            *\r\n          <\/span>\r\n        <\/label>\r\n        <div id=\"cid_5\" class=\"form-input-wide jf-required\" data-layout=\"half\">\r\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\r\n            <input type=\"tel\" id=\"input_5_full\" name=\"q5_phoneNumber[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[required, Fill Mask]\" style=\"width:310px\" data-masked=\"true\" value=\"\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_5 sublabel_5_masked\" required=\"\" \/>\r\n            <label class=\"form-sub-label\" for=\"input_5_full\" id=\"sublabel_5_masked\" style=\"min-height:13px\" aria-hidden=\"false\"> Please enter a valid phone number. <\/label>\r\n          <\/span>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_6\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_6\" for=\"input_6\"> Check any of the below symptoms you have: <\/label>\r\n        <div id=\"cid_6\" class=\"form-input-wide\" data-layout=\"full\">\r\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_6\" data-component=\"checkbox\">\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_0\" name=\"q6_checkAny[]\" value=\"Occasional blurring of vision, especially with reading or computer work\" \/>\r\n              <label id=\"label_input_6_0\" for=\"input_6_0\"> Occasional blurring of vision, especially with reading or computer work <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_1\" name=\"q6_checkAny[]\" value=\"Redness\" \/>\r\n              <label id=\"label_input_6_1\" for=\"input_6_1\"> Redness <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_2\" name=\"q6_checkAny[]\" value=\"Burning\/Pain\" \/>\r\n              <label id=\"label_input_6_2\" for=\"input_6_2\"> Burning\/Pain <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_3\" name=\"q6_checkAny[]\" value=\"Itching\" \/>\r\n              <label id=\"label_input_6_3\" for=\"input_6_3\"> Itching <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_4\" name=\"q6_checkAny[]\" value=\"Light Sensitivity\" \/>\r\n              <label id=\"label_input_6_4\" for=\"input_6_4\"> Light Sensitivity <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_5\" name=\"q6_checkAny[]\" value=\"Excess tearing \/ watering eyes\" \/>\r\n              <label id=\"label_input_6_5\" for=\"input_6_5\"> Excess tearing \/ watering eyes <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_6\" name=\"q6_checkAny[]\" value=\"Tired eyes\" \/>\r\n              <label id=\"label_input_6_6\" for=\"input_6_6\"> Tired eyes <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_7\" name=\"q6_checkAny[]\" value=\"Contact lens discomfort\" \/>\r\n              <label id=\"label_input_6_7\" for=\"input_6_7\"> Contact lens discomfort <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_6\" class=\"form-checkbox\" id=\"input_6_8\" name=\"q6_checkAny[]\" value=\"Feeling of sand or grit in the eye\" \/>\r\n              <label id=\"label_input_6_8\" for=\"input_6_8\"> Feeling of sand or grit in the eye <\/label>\r\n            <\/span>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_11\">\r\n        <div id=\"cid_11\" class=\"form-input-wide\" data-layout=\"full\">\r\n          <div id=\"text_11\" class=\"form-html\" data-component=\"text\">\r\n            <p><span style=\"font-family: arial, helvetica, sans-serif;\">Report the FREQUENCY of symptoms you are experiencing using the following numbering system: <br \/><strong>0<\/strong>= Never,<strong> 1<\/strong>= Sometimes, <strong>2<\/strong>= Often, <strong>3<\/strong>= Constant<\/span><\/p>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_10\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10\"> Dryness, Grittiness or Scratchiness <\/label>\r\n        <div id=\"cid_10\" class=\"form-input-wide\" data-layout=\"half\">\r\n          <select class=\"form-dropdown\" id=\"input_10\" name=\"q10_drynessGrittiness\" style=\"width:310px\" data-component=\"dropdown\">\r\n            <option value=\"\"> Please Select <\/option>\r\n            <option value=\"0\"> 0 <\/option>\r\n            <option value=\"1\"> 1 <\/option>\r\n            <option value=\"2\"> 2 <\/option>\r\n            <option value=\"3\"> 3 <\/option>\r\n          <\/select>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_12\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_12\" for=\"input_12\"> Soreness or Irritation <\/label>\r\n        <div id=\"cid_12\" class=\"form-input-wide\" data-layout=\"half\">\r\n          <select class=\"form-dropdown\" id=\"input_12\" name=\"q12_sorenessOr\" style=\"width:310px\" data-component=\"dropdown\">\r\n            <option value=\"\"> Please Select <\/option>\r\n            <option value=\"0\"> 0 <\/option>\r\n            <option value=\"1\"> 1 <\/option>\r\n            <option value=\"2\"> 2 <\/option>\r\n            <option value=\"3\"> 3 <\/option>\r\n          <\/select>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_13\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_13\" for=\"input_13\"> Burning or Watering <\/label>\r\n        <div id=\"cid_13\" class=\"form-input-wide\" data-layout=\"half\">\r\n          <select class=\"form-dropdown\" id=\"input_13\" name=\"q13_burningOr\" style=\"width:310px\" data-component=\"dropdown\">\r\n            <option value=\"\"> Please Select <\/option>\r\n            <option value=\"0\"> 0 <\/option>\r\n            <option value=\"1\"> 1 <\/option>\r\n            <option value=\"2\"> 2 <\/option>\r\n            <option value=\"3\"> 3 <\/option>\r\n          <\/select>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_15\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_15\" for=\"input_15\"> Do you use (check all that apply): <\/label>\r\n        <div id=\"cid_15\" class=\"form-input-wide\" data-layout=\"full\">\r\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_15\" data-component=\"checkbox\">\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_15\" class=\"form-checkbox\" id=\"input_15_0\" name=\"q15_doYou15[]\" value=\"Over-the-counter drops to treat your dry eyes\" \/>\r\n              <label id=\"label_input_15_0\" for=\"input_15_0\"> Over-the-counter drops to treat your dry eyes <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_15\" class=\"form-checkbox\" id=\"input_15_1\" name=\"q15_doYou15[]\" value=\"Prescription eye drops for dry eyes\u200e\" \/>\r\n              <label id=\"label_input_15_1\" for=\"input_15_1\"> Prescription eye drops for dry eyes\u200e <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_15\" class=\"form-checkbox\" id=\"input_15_2\" name=\"q15_doYou15[]\" value=\"Eye drops for glaucoma\u200e\" \/>\r\n              <label id=\"label_input_15_2\" for=\"input_15_2\"> Eye drops for glaucoma\u200e <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_15\" class=\"form-checkbox\" id=\"input_15_3\" name=\"q15_doYou15[]\" value=\"Eye drops for allergies\u200e\" \/>\r\n              <label id=\"label_input_15_3\" for=\"input_15_3\"> Eye drops for allergies\u200e <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_15\" class=\"form-checkbox\" id=\"input_15_4\" name=\"q15_doYou15[]\" value=\"Nutritional supplements for eyes\u200e\" \/>\r\n              <label id=\"label_input_15_4\" for=\"input_15_4\"> Nutritional supplements for eyes\u200e <\/label>\r\n            <\/span>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_16\">\r\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_16\" for=\"input_16\"> Have you had surgery for: <\/label>\r\n        <div id=\"cid_16\" class=\"form-input-wide\" data-layout=\"full\">\r\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_16\" data-component=\"checkbox\">\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_16\" class=\"form-checkbox\" id=\"input_16_0\" name=\"q16_haveYou[]\" value=\"Cataracts\" \/>\r\n              <label id=\"label_input_16_0\" for=\"input_16_0\"> Cataracts <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_16\" class=\"form-checkbox\" id=\"input_16_1\" name=\"q16_haveYou[]\" value=\"Glaucoma\" \/>\r\n              <label id=\"label_input_16_1\" for=\"input_16_1\"> Glaucoma <\/label>\r\n            <\/span>\r\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\r\n              <span class=\"dragger-item\">\r\n              <\/span>\r\n              <input type=\"checkbox\" aria-describedby=\"label_16\" class=\"form-checkbox\" id=\"input_16_2\" name=\"q16_haveYou[]\" value=\"Refractive surgery (LASIK)\" \/>\r\n              <label id=\"label_input_16_2\" for=\"input_16_2\"> Refractive surgery (LASIK) <\/label>\r\n            <\/span>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_17\">\r\n        <div id=\"cid_17\" class=\"form-input-wide\" data-layout=\"full\">\r\n          <div data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\">\r\n            <button id=\"input_17\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">\r\n              Submit\r\n            <\/button>\r\n          <\/div>\r\n        <\/div>\r\n      <\/li>\r\n      <li style=\"display:none\">\r\n        Should be Empty:\r\n        <input type=\"text\" name=\"website\" value=\"\" \/>\r\n      <\/li>\r\n    <\/ul>\r\n  <\/div>\r\n  <script>\r\n  JotForm.showJotFormPowered = \"0\";\r\n  <\/script>\r\n  <script>\r\n  JotForm.poweredByText = \"Powered by JotForm\";\r\n  <\/script>\r\n  <script>\r\n  JotForm.hipaa = true;\r\n  <\/script>\r\n  <script>\r\n  JotForm.showHIPAABadge = true;\r\n  <\/script>\r\n  <input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"212007278264048\" \/>\r\n  <script type=\"text\/javascript\">\r\n  var all_spc = document.querySelectorAll(\"form[id='212007278264048'] .si\" + \"mple\" + \"_spc\");\r\nfor (var i = 0; i < all_spc.length; i++)\r\n{\r\n  all_spc[i].value = \"212007278264048-212007278264048\";\r\n}\r\n  <\/script>\r\n<\/form>\r\n<script type=\"text\/javascript\">JotForm.forwardToHIPAA=true;<\/script><script src=\"https:\/\/cdn.jotfor.ms\/\/js\/vendor\/smoothscroll.min.js?v=3.3.26544\"><\/script>\r\n<script src=\"https:\/\/cdn.jotfor.ms\/\/js\/errorNavigation.js?v=3.3.26544\"><\/script>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>DRY EYE SELF-EVALUATION &nbsp; Thank you for your interest. Dry eye disease is one of the most frequent reasons that patients visit eye doctors. Please complete this dry eye disease self-evaluation to determine if you might be suffering from dry eye. Name * First Name Last Name Email * example@example.com Phone Number * Please enter &#8230; <a title=\"Dry Eye Self Evaluation\" class=\"read-more\" href=\"https:\/\/www.medicaleyecenter.com\/specialties\/dry-eye\/self-evaluation\/\" aria-label=\"More on Dry Eye Self Evaluation\">Read more<\/a><\/p>\n<div class='the_champ_sharing_container the_champ_vertical_sharing the_champ_hide_sharing the_champ_bottom_sharing' style='width:44px;left: -10px;top: 300px;-webkit-box-shadow:none;box-shadow:none;' data-super-socializer-href=\"https:\/\/www.medicaleyecenter.com\/wp-json\/wp\/v2\/pages\/8074\"><div class=\"the_champ_sharing_ul\"><a aria-label=\"Facebook\" class=\"the_champ_facebook\" href=\"https:\/\/www.facebook.com\/sharer\/sharer.php?u=https%3A%2F%2Fwww.medicaleyecenter.com%2Fwp-json%2Fwp%2Fv2%2Fpages%2F8074\" title=\"Facebook\" rel=\"nofollow noopener\" target=\"_blank\" style=\"font-size:24px!important;box-shadow:none;display:inline-block;vertical-align:middle\"><span 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Let our eye doctors in Medford and Grants Pass help you today!\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.medicaleyecenter.com\/specialties\/dry-eye\/self-evaluation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Dry Eye Self Evaluation\" \/>\n<meta property=\"og:description\" content=\"Fill out this simple form to see if you need help diagnosing dry eye issues. 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