Dry Eye Questionnaire

Dry Eye Questionnaire
Questions about Eye Discomfort:
During a typical day in the past month, how often did your eyes feel discomfort?*

NeverRarelySometimesFrequentlyConstantly
When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within 2 hours of going to bed?*

0

1

2

3

4

5

0 is Not at all Intense, 5 is Very Intense
Questions about Eye Dryness:
During a typical day in the past month, how often did your eyes feel dry?*

NeverRarelySometimesFrequentlyConstantly
When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within 2 hours of going to bed?*

0

1

2

3

4

5

0 is Not at all Intense, 5 is Very Intense
Questions about Watery Eyes:
During a typical day in the past month, how often did your eyes look or feel excessively watery?*

NeverRarelySometimesFrequentlyConstantly
Name*

First NameLast Name
Email
example@example.com
Calculation
Should be Empty:

Questions about Eye Discomfort: