Dry Eye Questionnaire
Answer the following questions based on the last week and follow the steps to get your score to help determine if you may have Chronic Dry Eye disease. Share your results with your eye doctor.
Name:
First Name
Last Name
Email:
example@example.com
A) Have you experienced any of the following physical symptoms?
All of the time
Most of the time
Half of the time
Sometimes
None of the time
Eyes that are sensitive to light
Eyes that feel gritty
Painful or sore eyes
Blurred vision
Poor vision
Section A Total:
B) Have problems (daily symptoms) with your eyes limited you in performing the following?
All of the time
Most of the time
Half of the time
Sometimes
None of the time
Reading
Driving at night
Working with a computer
Watching TV
Section B Total:
C) Have your eyes felt uncomfortable in any of the following situations (environmental factors)?
All of the time
Most of the time
Half of the time
Sometimes
None of the time
Windy conditions
Places with low humidity (very dry)
Areas that are air conditioned
Section C Total:
D) Section A, B and C Total:
E) Total Questions Answered (out of 12)?
Locate "E" on the vertical axis of the Dry Eye Severity Scale. "None of the time" does not count as an answered question.
F) Dry Eye Score:
Where D & E meet is where your score falls on the Dry Eye Severity Scale
Submit
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