EyeSouth Partners - Dry Eye Questionnaire (DEQ-5) -19Apr2022

Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Questions about EYE DISCOMFORT:
1A. During a typical day in the past month, how often did your eyes feel discomfort?*

NEVER = 0RARELY = 1SOMETIMES = 2FREQUENTLY = 3CONSTANTLY = 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 = 0NOT AT ALL INTENSE = 1A LITTLE INTENSE = 2SOMEWHAT INTENSE = 3QUITE INTENSE = 4VERY INTENSE = 5
Questions about EYE DRYNESS:
2A. During a typical day in the past month, how often did your eyes feel dry?*

NEVER = 0RARELY = 1SOMETIMES = 2FREQUENTLY = 3CONSTANTLY = 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 = 0NOT AT ALL INTENSE = 1A LITTLE INTENSE = 2SOMEWHAT INTENSE = 3QUITE INTENSE = 4VERY 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 = 0RARELY = 1SOMETIMES = 2FREQUENTLY = 3CONSTANTLY = 4
Your Total Score (Hidden Field)
Proposed screening criteria for the DEQ-5 is >6 for Dry Eye.
Please verify that you are human*
Should be Empty: