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Date*

Dry Eye Disease is the most frequent reason the patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questions below.

Report the FREQUENCY of the dry eye symptoms. How many times are you experiencing the symptoms?

Dryness, Gritiness or Scratchiness

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

Soreness or Irritation

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

Burning or Watering

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

Eye Fatigue

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

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Result - FREQUENCY of the dry eye symptoms

Report the SEVERITY of the dry eye symptoms Never = 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

Dryness, Gritiness or Scratchiness

0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable

Soreness or Irritation

0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable

Burning or Watering

0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable

Eye Fatigue

0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable

Please check if you have experienced these symptoms

Today
Within the past 72 hours
Within past 3 months

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Result - SEVERITY of the dry eye symptoms

Do you use eye drops and/or ointments?

Yes
No

Name of drops

Have you used them today?

Yes
No

How long are they effective?

Do the drops last 4 hours?

Yes
No

Do any gels last 12 hours?

Yes
No

Did you use Moisturizers, lotions or creams around eyes today?

Yes
No

Did you use makeup today?

Yes
No

Have you touched/rubbed your eye(s) today?

Yes
No

If yes, when?

How?

Have you ever been told you have BLEPHARITIS?

Yes
No

STYE?

Yes
No

Do you have fluctuating vision problems (that gets better with BLINKING)?

Never
Sometimes
Frequently
A lot/always

Dry Eye Questionnaire

Dry Eye Questionnaire

Heights Eye Center