OD Dry Eye Research Tracking Form
Aston University Dry Eye Research Study
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Reference ID
Date of Appointment
-
Month
-
Day
Year
Appointment Type
Please Select
-30
Day 0
Day 15
Day 45
Day 75
Group:
A
B
DEQ-5 Score
Non-invasive break-up time (NIBUT) - Seconds (0-30)
Tear Prism Height - mm (0.0-1mm)
Meibgraphy Scale- Five-grade meiboscale (Dr Heiko Pult)
Please Select
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
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of
Corneal Dryness Spots Number (0-100)
Corneal Dryness
Please Select
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
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of
Meibomian Gland Dysfunction Corneal Dryness
Please Select
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
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of
Conjunctival Redness
Please Select
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
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of
Patient Treatment Compliance - Since your last visit on average how many times per day have you used the following:
Rows
Number of Times Per Day
Drops (0-1-2-3-4-5-6-6+)
Wipes (0 - 1 - 2)
Mask (0 - 1 – 2 applications per day)
OMEGA (0 - 1 – 2 pills/liquid spoons per day)
Submit
Should be Empty: