Dry Eye Questionnaire

Dry Eye Questionnaire
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
NeverSometimesOftenConstant
NeverSometimesOftenConstant
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
Your Score is:
Score 0-4: You are experiencing MILD dry eye symptoms
Score 5-7: You are experiencing MODERATE dry eye symptoms
Score 8+: You are experiencing SEVERE dry eye symptoms
YesNo
Should be Empty: