Katzen - Dry Eye Questionnaire (DEQ-5) - Eyecare Services Partners

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Questions about EYE DISCOMFORT:

1A. During a typical day in the past month, how often did your eyes feel discomfort? *

NEVER = 0 RARELY = 1 SOMETIMES = 2 FREQUENTLY = 3 CONSTANTLY = 4

1B. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed? *

NEVER HAVE IT = 0 NOT AT ALL INTENSE = 1 A LITTLE INTENSE = 2 SOMEWHAT INTENSE = 3 QUITE INTENSE = 4 VERY INTENSE = 5

Questions about EYE DRYNESS:

2A. During a typical day in the past month, how often did your eyes feel dry? *

NEVER = 0 RARELY = 1 SOMETIMES = 2 FREQUENTLY = 3 CONSTANTLY = 4

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

NEVER HAVE IT = 0 NOT AT ALL INTENSE = 1 A LITTLE INTENSE = 2 SOMEWHAT INTENSE = 3 QUITE INTENSE = 4 VERY INTENSE = 5

Question about WATERY EYES:

3. During a typical day in the past month, how often did your eyes look or feel excessively watery? *

NEVER = 0 RARELY = 1 SOMETIMES = 2 FREQUENTLY = 3 CONSTANTLY = 4

Your Total Score (Hidden Field)

Proposed screening criteria for the DEQ-5 is >6 for Dry Eye.

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