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Welcome to TearWell,

We are a unique clinical facility dedicated exclusively to the diagnosis and treatment of Dry Syndrome. TearWell is located within the FocalPoint at Crosstown Concourse, in Suite 264 on the second floor of the historic Crosstown Concourse building at 1350 Concourse Avenue. Free parking is readily available in front of building and a covered parking garage.

Remember not to use any eye drops 4 hours prior to your appointment, and no gel, ointments or contact lenses the night before. Also, please do not wear any eye makeup or thick lotions/ moisturizing creams near the to avoid interference with some of the testing we will be performing during your evaluation.

Your appointment will last between 1.5 and 2 hours and you will not be dilated or your vision affected in any way.

Please bring a list of all your eye drops and other dry eye therapies you are currently using or have tried in the past, as well as a list of all medications you are currently taking.

Enclosed is some of the paperwork we would have you fill out at the time of your visit, feel free to complete it before hand to expedite the check in process.

We look forward to seeing you; let us know if you have any questions or if there’s anything else we can do before your appointment.

Thank you,

Ramon Gomez Eyecare Concierge 901.252.3670 [email protected] Making Your TearWell Appointment

You’ve suffered from dry eyes long enough. Take the first step in NORTH PARKWAY finding lasting relief at the TearWell Advanced Dry Eye Treatment Center in midtown Memphis. TearWell has quickly become the leading center in the Mid-South for the diagnosis and treatment of dry .

CROSSTOWN GALLOWAY AVE CENTRAL CONCOURSE ATRIUM With the expertise of three of the leading optometric physicians ST N WATKINS CONCOURSE AVENUE who have devoted much of their career to treating dry eye PARKING disease, TearWell additionally benefits from its association GARAGE with one of the nation’s leading optometry colleges and clinical AUTUMN AVENUE

N CLEVELAND ST GARLAND ST facilities.

Schedule your appointment today to begin a consultation to ST N CLAYBROOK explore the best treatment option for you. The TearWell Advanced Dry Eye Treatment Center’s primary Call 901.252.3670 or email [email protected]. location is open Monday-Friday from 8:30am - 5pm in The You may also visit TearWell.com to learn more. FocalPoint at Crosstown Concourse operated by Southern College of Optometry in Memphis. Located in Suite 264 on the Here’s how to visit us: second floor of the historic Crosstown Concourse building at 1350 Concourse Avenue, TearWell offers exclusive treatment DRY EYE options dedicated to the treatment of Dry Eye Disease and Located in The FocalPoint at Crosstown Concourse, operated by dry eye symptoms. Southern College of Optometry, in Suite 264 on the second floor of the historic Crosstown Concourse building at 1350 Concourse TearWell is conveniently located with 15-25 minute drives Avenue. TearWell offers exclusive treatment options dedicated from Collierville, Cordova, Germantown, Southaven and West RELIEF to the treatment of Dry Eye Disease and dry eye symptoms. Memphis. We offer free, convenient parking located in the Crosstown Concourse parking garage. TearWell is conveniently located with 15-25 minute drives from Collierville, Cordova, Germantown, Southaven and West Memphis. We offer free, convenient parking located in the Crosstown Concourse parking garage. TM TM

Financing Available 901.252.3670 tearwell.com | [email protected] 901.252.3670 tearwell.com | [email protected] facebook.com/ *Financing options for LipiFlow are available tearwellcenter @TearWellCenter 1350 Concourse Avenue at Crosstown Concourse through a third party financing company. Your Dry Eye Relief Starts Now Meet Your Doctors This information packet marks the start of finding the optimal relief Whitney Hauser, OD Arizona. In 2013, Dr. Grant joined Southern College of Optometry, where your dry eyes need. If dry eye relief has eluded you, TearWell brings she currently serves as a Clinical Instructor in The Eye Center. She is is the Clinic Development Consultant of TearWell you new opportunities to treat your symptoms. a member of the Tennessee Public Health Association, Tennessee Advanced Dry Eye Treatment Center. Dr. Hauser Association of Optometric Physicians and the American Optometric graduated from The University of Tennessee at TearWell offers the expertise of three optometric physicians Association. known for their research and extensive experience in treating Knoxville with a bachelor’s degree in Biology. She ocular surface disease, including dry eye disease. TearWell obtained her Doctor of Optometry at Southern College of Optometry (SCO) with the academic distinction magna cum Kristina Haworth, OD focuses exclusively on dry eye treatment. laud and completed her residency in Primary Care through SCO and the serves as Associate Professor at Southern College VA Medical Center in Memphis. She was also a member of Beta Sigma of Optometry. She served as Assistant Professor Kappa Honor Society. at The Ohio State University from 2011-2015. “TearWell has given me Dr. Hauser was in private practice for 10 years where her concentration While she was at Ohio State she earned both an new hope in finding the was Dry Eye and Ocular Surface Disease management as well as surgical M.S. and Ph.D. in Vision Science. Before that, she pre and post-operative care. She is an active member of the American earned her O.D. from Southern California College of Optometry. Prior help I needed.” Optometric Association, Ocular Nutrition Society, the Association for to her academic career, Dr. Haworth was part of an interdisciplinary Research in Vision and , the World Congress of Optometry ophthalmology and optometry practice for 7 years before opening her and Women of Vision. Dr. Hauser is also an avid runner and fitness own solo optometric practice in California. It’s never been a better time to take advantage of the innovative, enthusiast. At Southern College of Optometry, Dr. Haworth supervises clinicians diagnostic testing that allows TearWell to create a customized in The Eye Center and at the University Eye Center. She also conducts treatment for each patient. TearWell is the first treatment center research related to findings from her Ph.D. dissertation. ® Rachel Grant, OD in the Memphis area to offer LipiFlow, the only FDA-approved Dr. Haworth holds optometry licenses in California, Ohio, Oregon and treatment for dry eye disease. graduated from the University of Victoria, in British Tennessee. She is a Fellow of the American Academy of Optometry. Columbia, Canada. She obtained her Doctor Her research focus is in ocular surface and dry eye conditions. She has At TearWell, we’re committed to understanding your needs. We of Optometry at Southern California College of published manuscripts in peer-reviewed journals and has presented look forward to meeting you and building a relationship as we Optometry (SCCO) at Marshall B. Ketchum University some of her findings at national annual meetings of the American explore the best treatment options available for you. and completed her residency training in Primary Academy of Optometry and the Association for Research in Vision and Care and Ocular Disease at Hu Hu Kam Memorial Hospital in Sacaton, Ophthalmology (ARVO) through scientific papers and posters. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I understand and acknowledge that in an attempt to protect the privacy of my identifi able health information, The Eye Center at Southern College of Optometry has established a Notice of Privacy Practices. This information details the use and disclosure of information contained in my personal medical records kept for the purposes of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the The Eye Center at Southern College of Optometry’s Notice of Privacy Practices has been made available to me while in the facility today. Should I choose to have a personal copy, one will be given to me at no charge. You can access this document at www.tec.sco.edu/patients/documents/GC-120A_notice_of_privacy_practices.pdf

Patient Signature, if not a minor Date

If patient is a minor, parent/legal guardian sign here Date

If patient is a minor, agent for the Legal Custodian Date

GC-120B 08/10 | Medical History Name:______Date:______Email: ______Birth Date:______Last Eye Exam (date):______Last Eye Doctor (name):______Last Medical Exam (date): ______Last Medical Doctor (name):______

What is your eye problem/complaint today? Please describe this problem you are having as best as you can. ______

Patient Ocular/Medical History Yes No Social History Yes No Do you smoke? If YES, do you smoke every day? If NO, did you used to smoke? Eye Injury Do you use recreational drugs Retinal Disease Do you drink alcohol? Loss of Vision/Blindness Are you currently pregnant or nursing? Eye Turn/ What is your occupation? Lazy Eye/Amblyopia What are your hobbies? Eye Infection How many hours a day do you use a computer? Dry Eye What is your current height? High Blood Pressure/Hypertension What is your current weight? Diabetes Other Disease(s)/Prematurity Patient Review of Health Do you wear ? Do you currently have or ever had problems in the following areas? Yes No Do you wear contact lenses? Constitution (Fever, Weight Gain/Loss) If NO, would you like to? Cardiovascular/Vascular (Diabetes, High Blood Pressure, Stroke) Have you ever had a surgery on your eyes? Ears, Nose, Throat, Mouth (Allergies, Sinus Congestion, Dryness) If YES, what was it? Why did you have it performed? Respiratory (Asthma, Bronchitis, Emphysema) Gastrointestinal (Diarrhea, Constipation) Genitourinary (Genitals, Kidney, Bladder Problems) Musculoskeletal (Arthritis, Joint/Muscle Pain) Yes No Family Ocular/Medical History Integumentary (Skin Problems) Glaucoma Neurological (Headaches, Migraines, Seizures) Cataracts Psychiatric (Mental/Emotional Problems) Macular Degeneration Endocrine (Thyroid/Other Gland Problem) Eye Injury Hematologic/Lymphatic (Anemia, Bleeding Problems) Retinal Disease Allergic/Immunologic (Allergy) Loss of Vision/Blindness Eye Turn/Strabismus Lazy Eye/Amblyopia Medications List all medications that you currently take (including over-the- Eye Infection counter, vitamins, supplements, oral contraceptives, etc.) Dry Eye High Blood Pressure/Hypertension Diabetes Other Disease(s)/Prematurity

What is your preferred pharmacy? ______Phone Number:______Do you have any allergies to medications?______Do you have environmental allergies?______TW-106 (07/14) | Ocular Surface Disease Index

Everyone experiences some eye discomfort. But if your eyes frequently burn, itch, or feel gritty, you may be experiencing symptoms of Dry Eye Disease. Please answer the questions below and fill in boxes in A,B,C,D and E. Be sure to give the completed form to your BEFORE your exam.

Have you experienced any of the following During the last week?

All of the Most of the Half of the Some of the None of the A. Physical Symptoms time time time time time

1 Eyes that are sensitive to light 4 3 2 1 0 N/A 2 Eyes that feel gritty 4 3 2 1 0 N/A 3 Painful or sore eyes 4 3 2 1 0 N/A 4 4 3 2 1 0 N/A 5 Poor vision 4 3 2 1 0 N/A

Subtotal score for answers 1 to 5 A

Have problems with your eyes limited you in performing any of the following During the last week?

All of the Most of the Half of the Some of the None of the B. Daily Activities time time time time time

6 4 3 2 1 0 N/A 7 Driving at night 4 3 2 1 0 N/A Working with a computer or 4 3 2 1 0 N/A 8 bank machine (ATM) 9 Watching TV 4 3 2 1 0 N/A

Subtotal score for answers 6 to 9 B

Have your eyes felt uncomfortable in any of the following situations During the last week? C. Environmental All of the Most of the Half of the Some of the None of the Factors time time time time time 10 Windy conditions 4 3 2 1 0 N/A Places or areas with low hu- 4 3 2 1 0 N/A 11 midity (very dry)

12 Areas that are air conditioned 4 3 2 1 0 N/A

Subtotal score for answers 10 to 12 C

Add subtotals A,B, and C to obtain D ______(D) Total number of questions answered ______(E)

Name______Date______

TW-108 (08/14) | Speed Questionnaire

First name______Last name______

Date of birth ______Gender q Male q Female Account# ______

How FREQUENTLY do you experience the following dry eye symptoms?

Symptoms Never (0) Sometimes (1) Often (2) Constant (3) Dryness, grittiness or scratchiness Soreness or irritation Burning or watering Eye fatigue

How SEVERE are your dry eye symptoms?

Symptoms No Problems Tolerable Uncomfortable Bothersome Intolerable (0) not perfect but irritating & irritating & unable to not interferes with interferes with perform my uncomfortable my day my day daily tasks (1) (2) (3) (4)

Dryness, grittiness or scratchiness Soreness or irritation Burning or watering Eye fatigue

WHEN have you experienced these symptoms? q Today q Within the last past 72 hours q Within the past 3 months

Symptoms Yes No Do you have difficulty reading? Do you have difficulty using a computer? Do you have difficulty driving? Do you have difficulty watching television? Do you have difficulty wearing contact lenses? Do you have difficulty being outdoors? Do your symptoms worsen throughout the day?

Do you use eye drops and/or ointment? q Yes q No If yes, which drops do you use? How frequently do you use them? ______

Have you been told that you have or have you been treated for a ? Blephartis q Yes q No Stye q Yes q No In what way is dry eye negatively impacting your life the most? ______

TW-107 (08/14) TearWell Advanced Dry Eye Treatment Center

Clinically Proven

Many people with Dry Eye have now been treated with LipiFlow®

including patients in a multi-center NORTH PARKWAY clinical trial. During this trial most (79%) of patients reported improvement in their overall Dry Eye symptoms within four weeks.1,2 CROSSTOWN GALLOWAY AVE CENTRAL CONCOURSE ATRIUM

N WATKINS ST N WATKINS CONCOURSE AVENUE

PARKING “My eyes were in an increasing GARAGE AUTUMN AVENUE

problem for me. My whole N CLEVELAND ST GARLAND ST quality of life was definitely

impacted. Now there are days ST N CLAYBROOK that go by I don’t need my eye drops. It’s a matter of reclaiming The TearWell Advanced Dry Eye Treatment Center’s primary hours of my life.” location is open Monday-Friday from 8:30am - 5pm in The – Noelle FocalPoint at Crosstown Concourse operated by Southern College of Optometry in Memphis. Located in Suite 264 on the second floor of the historic Crosstown Concourse building at 1350 Concourse Avenue, TearWell offers exclusive treatment options dedicated to the treatment of Dry Eye Disease and “Now I’m back to being active. dry eye symptoms. I can run, I can bike ride. I have an 8 year old and can do all the TearWell is conveniently located with 15-25 minute drives things that I want to do with him. from Collierville, Cordova, Germantown, Southaven and West I couldn’t do a lot of that before. Memphis. We offer free, convenient parking located in the Dry eyes It’s changed my life. It really has.” Crosstown Concourse parking garage. holding you – Brigette back?

TM “The realization that I was benefiting from the procedure Ask TearWell™ about LipiFlow.® came in the fact that I wasn’t thinking about my eyes.” ™ – Robert 901.252.3670 tearwell.com | [email protected]

facebook.com/ @TearWellCenter 1 Lane SS, et al. A New System, the LipiFlow, for the Treatment of tearwellcenter Meibomian Gland Dysfunction (MGD). 1/4/12. 2 Data on File. TearWell Advanced Dry Eye Treatment Center

Imagine returning to doing the things you enjoy, without thinking Think you may Tear about your eyes. Well ® have dry eye? Advanced Dry Eye Treatment Center LipiFlow could be your first step to relief. Take the quiz below TearWell to find out. Advanced Dry Eye Treatment Center

® Do you experience sensitivity to Not Enough Tears? Relief with LipiFlow light, blurred vision, a burning LipiFlow® is a procedure sensation, or discomfort in windy The most common form of Dry Eye is designed to treat or dry conditions? Evaporative Dry Eye, which affects 9 the root cause of Evaporative Dry Eye, out of 10 Dry Eye cases (86%)1. This form blocked Meibomian glands. O Yes O No results from a shortage of oil on the surface of your tears caused by a blockage in your LipiFlow® works by applying directed Have you decreased your (Meibomian) glands, leading tears to energy to the eyelid near the affected participation in or experienced evaporate faster than usual. glands — precisely targeted warmth from discomfort during any of the the back of the eye lid, and slight pressure following activities? Lipid (Oil) Layer (check all that apply) Lubricates and prevents from the front. This treatment is performed evaporation right in your doctor’s office. O Outdoor Activities Aqueous (Water) Layer O Reading Nourishes and protects the cornea O Watching TV O Using the computer Mucin Layer Adheres tears to the eye

Meibomian Glands Do you use drops for dry or Create the lipid (oil) layer of the tear film irritated eyes?

O Yes O No Your Evaluation Your TearWell™ doctor will perform a series of evaluations to determine the likely cause of your Dry Eye. This can include a LipiView Controlled If you answered yes to any of tear film assessment and a Meibomian Warmth the questions above, ask your gland evaluation. Knowing what is doctor about LipiFlow®. causing your Dry Eye will help your doctor Meibomian Intermittent Gland determine the best treatment option. Massage

1 Lemp MA, et al. Distribution of aqueous deficient and evaporative dry eye in a clinic-based patient population. Cornea. 2012 May;31(5):472-8. Tarsal Plate