Dry Eye Questionnaire Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Sex* Male FemaleDate* 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 Scratchiness 0 - Never 1 - Sometimes 2 - Often 3 - ConstantSoreness or Irritation 0 - Never 1 - Sometimes 2 - Often 3 - ConstantBurning or Watering 0 - Never 1 - Sometimes 2 - Often 3 - ConstantEye Fatigue 0 - Never 1 - Sometimes 2 - Often 3 - ConstantReport the SEVERITY of the dry eye symptomsNever = 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 Scratchiness 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - IntolerableSoreness or Irritation 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - IntolerableBurning or Watering 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - IntolerableEye Fatigue 0 - Never 1 - Tolerable 2 - Uncomfortable 3 - Bothersome 4 - IntolerablePlease check if you have experienced these symptoms Today Within the past 72 hours Within past 3 monthsDo you use eye drops and/or ointments? Yes NoName of dropsHave you used them today? Yes NoHow long are they effective?Do the drops last 4 hours? Yes NoDo any gels last 12 hours? Yes NoDid you use Moisturizers, lotions or creams around eyes today? Yes NoDid you use makeup today? Yes NoHave you touched/rubbed your eye(s) today? Yes NoIf yes, when?How?Have you ever been told you have BLEPHARITIS? Yes NoSTYE? Yes NoDo you have fluctuating vision problems (that gets better with BLINKING)? Never Sometimes Frequently A lot/always
