Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

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

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

Symptoms

Dryness, Grittiness, Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue


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 interfere with my day
4 = Intolerable - unable to perform my daily tasks

Symptoms

Dryness, Grittiness, Scratchiness

Soreness or Irritation

Burning or Watering

Eye Fatigue

Contact Information

Name

Email Address

Phone Number

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