DEQ5
Dry Eye Questionnaire
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Questions about EYE DISCOMFORT:
During a typical day in the past month, how often did your eyes feel discomfort?
*
0 Never
1 Rarely
2 Sometimes
3 Frequently
4 Constantly
When your eyes felt discomfort, how intense was this feeling of discomfortat the end of the day, within two hours of going to bed?
*
0 Never have it
1 Not intense at all
2
3
4
5 Very intense
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Questions about EYE DRYNESS:
During a typical day in the past month, how often did your eyes feel dry?
*
0 Never
1 Rarely
2 Sometimes
3 Frequently
4 Constantly
When your eyes felt dry, how intense was this feeling of dryness at the endof the day, within two hours of going to bed?
*
0 Never have it
1 Not at all intense
2
3
4
5 Very intense
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Next
Questions about WATERY EYES:
During a typical day in the past month, how often did your eyes look or feel excessively watery?
*
0 Never
1 Rarely
2 Sometime
3 Frequently
4 Constantly
Submit
Should be Empty: