Dipyridamole Pre/Post Eye Drop Survey
MedInsight Research Institute is pleased to announce that Israel Pharmacy Ltd (BuyLDN.com) has agreed to support further dipryidamole research by providing a *10% discount coupon* to those who provide feedback about their experience using the eye drops, as indicated below. How can you participate in our survey and receive the discount?
1) BEFORE starting the drops, complete this online survey and take quality "pre" pictures of your affected eye(s) (if you have visible symptoms such as redness, pterygium, pinguecula).
2) AFTER starting the drops, complete the survey again (preferably monthly) and take quality"post" pictures of your affected eye(s) at the same time.
Please send your pictures to shira@medinsight.org. A one-time use coupon will be sent to you for each completed survey/picture received (max 1 per month).
Participating in our survey will help track your treatment progress and advance our understanding. Information and pictures may be used for the purpose of advancing research into eye disease, and will only be shared anonymously, unless you give us explicit permission to do otherwise. To protect your anonymity, pictures will be cropped to show only the eye itself. We respect your right to privacy and confidentiality, and we appreciate your sharing feedback with us.
Your Condition(s) and Symptoms
How would you rate your eye health today? *
Please describe the condition(s) for which you are (or will be) using the dipyridamole eyedrops:
Your answer
How long have you had your condition(s)?
Your answer
What medical diagnosis (or diagnoses, if more than one) have you received regarding your eyes?
Your answer
Do you have any symptoms that are visible (e.g. redness, pterygium, pinguecula)?
(If yes, please take clear, non-blurry pictures of your affected eye(s) today and send to shira@medinsight.org)
Your Symptoms During the Last Week
Have you experienced any of the following during the last week? *
(4) All of the time
(3) Most of the time
(2) Half of the time
(1) Some of the time
(0) None of the time
Eyes that are sensitive to light
Eyes that feel gritty
Painful or sore eyes
Blurred vision
Poor vision
Burning or Watering
How SEVERE were any of the following symptoms during the last week? *
(4) Intolerable (unable to perform my daily tasks)
(3) Bothersome (irritating and interferes with my day)
(2) Uncomfortable (irritating but does not interfere with my day)
(1) Tolerable (not perfect but not uncomfortable)
(0) No problems
Eyes that are sensitive to light
Eyes that feel gritty
Painful or sore eyes
Blurred vision
Poor vision
Burning or Watering
Have problems with your eyes limited you in performing any of the following during the last week? *
(4) All of the time
(3) Most of the time
(2) Half of the time
(1) Some of the time
(0) None of the time
N/A Not applicable
Reading
Driving At Night
Working with a computer or bank machine (ATM)
Watching TV
Have your eyes felt uncomfortable in any of the following situations during the last week? *
(4) All of the time
(3) Most of the time
(2) Half of the time
(1) Some of the time
(0) None of the time
N/A Not applicable
Windy conditions
Places or areas with low humidity (very dry)
Areas that are air conditioned
If you use lubricating eye drops, approximately how many times have you used them during the last week?
(If you do not, please skip to next question)
Your answer
What treatments for your eye condition(s) have failed you previously?
(If you have answered this question before, please skip to next question)
Your answer
In the past week, have you used any OTHER medications (besides dipyridamole) to treat your eye condition?
If yes, what medications have you used?
Your answer
If you have already started using the dipyridamole eye drops, please answer the next questions. If not, skip to Final Items section.
On what date did you start using the dipyridamole eye drops?
(If you haven't started yet please skip to the next applicable question)
MM
/
DD
/
YYYY
How many drops are you using per day (on average)?
(If you haven't started yet please skip to the end)
Your answer
Have you seen a positive change in the appearance of your eye(s)?
Do you think your condition has improved (i.e. how often or severe your symptoms are)?
If you think your condition has improved, please describe how:
Your answer
Have you experienced any side effects (negative OR positive)?
If you have experienced any side effects (negative OR positive), please describe:
Your answer
Final Items
Do you drink caffeinated coffee (as opposed to decaffeinated) every day or most days?
If yes, how many cups of caffeinated coffeee do you drink each day (on average)?
Please provide your name: *
Your answer
Please indicate what city you reside in: *
Your answer
Please provide your email address: *
Your answer
Today's Date: *
MM
/
DD
/
YYYY
If you have any additional feedback for us, you can email us at shira@medinsight.org or leave it here:
Your answer
**Please send a current, clear, high resolution picture of your eye(s) to shira@medinsight.org.** Thank you very much for helping refine our understanding of dipyridamole eye drops by sharing your experience with us.
(Questions contributed from Allergan ODSI-2 Copyright © 1995 and TearScience, Inc.'s SPEED 2013 questionnaires)
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