Dry Eye Questionnaire 1. Report the FREQUENCY of your symptoms using the rating listt below :Dryness, Grittiness or Scratchiness* Never Sometimes Often Constant Soreness or Irritation* Never Sometimes Often Constant Burning or Watering* Never Sometimes Often Constant Eye Fatigue* Never Sometimes Often Constant 2. Report the SEVERITY of your symptoms using the rating list below:Dryness, Grittiness or Scratchiness* No Problems Tolerable - not perfect, but not uncomfortable Uncomfortable - irritating, but does not interfere with my day Bothersome - irritating and interferes with my day Intolerable - unable to perform my daily tasks Soreness or Irritation* No Problems Tolerable - not perfect, but not uncomfortable Uncomfortable - irritating, but does not interfere with my day Bothersome - irritating and interferes with my day Intolerable - unable to perform my daily tasks Burning or Watering* No Problems Tolerable - not perfect, but not uncomfortable Uncomfortable - irritating, but does not interface with my day Bothersome - irritating and interfere with my day Intolerable - unable to perform my daily tasks Eye Fatigue* No Problems Tolerable - not perfect, but not uncomfortable Uncomfortable - irritating, but does not interfere with my day Bothersome - irritating and interferes with my day Intolerable - unable to perform my daily tasks 3. Please check if you have experience above symtoms:* Today Within last 3 days Within past 3 months Do you use eye drops for lubrication?* Yes No How often*Do you have fluctuating vision* NEVER SOMETIMES FREQUENTLY ALWAYS If you choose any of the options except "Never", does the fluctuating vision improve with blinking and/or lubricating drops?* Yes No Have you been told you have blepharitis?* Yes No Have you been treated for a stye?* Yes No Have you had any of these symtoms recently?* EYELID REDNESS CRUSTING AROUND LASHED LID IRRITATION Do you wear contact lenses?* Yes No When was the last time you wore them?*Do your eyes feel worse when they're on?* Yes No Do your eyes itch?* NEVER SOMETIMES FREQUENTLY ALWAYS If you choose any of the options except "Never", do you have know environmental allergies or allergic conjunctivitis?* Yes No Are your ocular symptoms symmetric between both eyes?* Yes No Which eye is the most symptomatic?* RIGHT LEFT Do you mind wearing glasses and/or contact lenses for improving your vision?* Yes No Would you be willing to pay out-of-pockets costs to reduce or eliminate your dependence on them?* Yes No Please check on the following scale to describe your personality as best you can:* Easy Going Perfectionist Total SPEED scoreFrequency + SeverityWould you like to discuss your results with our team? Yes No Name First Last PhoneEmail Date MM slash DD slash YYYY Δ
