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Dry Eye Questionnaire

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Dry Eye Questionnaire

Please answer the following questions, and our doctors will review your submission and reply with the results!

Dry Eye Questionnaire

Survey to identify presence of dry eyes

Step 1 of 6

16%

Sex
- Male
- Female
Age
Please enter a number from 1 to 110.
Do you use eye drops for lubrication?
- Yes
- No
If you said YES to using drops, how often do you insert the drops?

TODAY? Dryness, Grittiness or Scratchiness*
- Yes
- No
TODAY? Soreness or Irritation*
- Yes
- No
TODAY? Burning or Watering*
- Yes
- No
TODAY? Eye Fatigue*
- Yes
- No

LAST 72 HOURS? Dryness, Grittiness or Scratchiness*
- Yes
- No
LAST 72 HOURS? Soreness or Irritation*
- Yes
- No
LAST 72 HOURS? Burning or Watering*
- Yes
- No
LAST 72 HOURS? Eye Fatigue*
- Yes
- No

LAST 3 MONTHS? Dryness, Grittiness or Scratchiness*
- Yes
- No
LAST 3 MONTHS? Soreness or Irritation*
- Yes
- No
LAST 3 MONTHS? Burning or Watering*
- Yes
- No
LAST 3 MONTHS? Eye Fatigue*
- Yes
- No

How often do you have the following symptoms?

0 = Never; 1 = Sometimes; 2 = Often; 3 = Constant
Dryness, Grittiness or Scratchiness*
Soreness or Irritation*
Burning or Watering*
Eye Fatigue*
Section Break
How SEVERE are the following symptoms?

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*
Soreness or Irritation*
Burning or Watering*
Eye Fatigue*

Name (optional only)
First Last
Email (optional)

If you would like us to reply with the results of this questionnaire please provide your email. WE DO NOT SPAM!
How can we help you?
Feel free to share any other information about your vision.
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