Dry Eye Questionnaire

Name (required)

Email (required)

Today's Date (required)

Sex
MaleFemale

Date of Birth

Report the type of SYMPTOMS you experience and when they occur:

Dryness, Grittiness or Scratchiness
TodayWithin past 72 hoursWithin past 3 months

Soreness or Irritation
TodayWithin past 72 hoursWithin past 3 months

Burning or Watering
TodayWithin past 72 hoursWithin past 3 months

Eye Fatigue
TodayWithin past 72 hoursWithin past 3 months

Report the FREQUENCY of your symptoms using the rating list below:

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

Dryness, Grittiness or Scratchiness
0123

Soreness or Irritation
0123

Burning or Watering
0123

Eye Fatigue
0123

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 my daily tasks

Dryness, Grittiness or Scratchiness
01234

Soreness or Irritation
01234

Burning or Watering
01234

Eye Fatigue
01234

Do you use eye drops for lubrication?
YesNo

If yes, how often?