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Home » Contact Us » Patient Forms » Dry Eye Questionnaire

Dry Eye Questionnaire

Dry Eye Questionnaire

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Date*
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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

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Heights Eye Center

227 1/2 Boulevard
Hasbrouck Heights, NJ 07604

Phone: 201-288-1109
Email: heightseyecenter227@gmail.com
(Do not send personal health information by email.)

Monday: 9:00 AM - 4:00 PM
Tuesday: 9:00 AM - 7:00 PM
Wednesday: 9:00 AM - 1:00 PM
Thursday: 9:00 AM - 7:00 PM
Friday: 9:00 AM - 3:00 PM
Saturday: Open the first Saturday of the month 9:00 am - 2:00 pm
Sunday: Closed

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Heights Eye Center
227 1/2 Boulevard
Hasbrouck Heights, NJ 07604
Phone: 201-288-1109
https://www.heightseyecenter.net

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