Dry Eye Questionnaire Name* First Last Date* Date Format: MM slash DD slash YYYY 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 Scratchiness0 - Never1 - Sometimes2 - Often3 - ConstantSoreness or Irritation0 - Never1 - Sometimes2 - Often3 - ConstantBurning or Watering0 - Never1 - Sometimes2 - Often3 - ConstantEye Fatigue0 - Never1 - Sometimes2 - Often3 - ConstantResult - FREQUENCY of the dry eye symptomsReport 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 tasksDryness, Gritiness or Scratchiness0 - Never1 - Tolerable2 - Uncomfortable3 - Bothersome4 - IntolerableSoreness or Irritation0 - Never1 - Tolerable2 - Uncomfortable3 - Bothersome4 - IntolerableBurning or Watering0 - Never1 - Tolerable2 - Uncomfortable3 - Bothersome4 - IntolerableEye Fatigue0 - Never1 - Tolerable2 - Uncomfortable3 - Bothersome4 - IntolerablePlease check if you have experienced these symptoms Today Within the past 72 hours Within past 3 months Result - SEVERITY of the dry eye symptomsDo you use eye drops and/or ointments?YesNoName of dropsHave you used them today?YesNoHow long are they effective?Do the drops last 4 hours?YesNoDo any gels last 12 hours?YesNoDid you use Moisturizers, lotions or creams around eyes today?YesNoDid you use makeup today?YesNoHave you touched/rubbed your eye(s) today?YesNoIf yes, when?How?Have you ever been told you have BLEPHARITIS?YesNoSTYE?YesNoDo you have fluctuating vision problems (that gets better with BLINKING)?NeverSometimesFrequentlyA lot/always
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