Form
Name
First Name
Last Name
How often do you experience dryness, grittiness or scratchiness?
0 - Never
1 - Sometimes
2 - Often
3 - Constant
How often do you experience soreness or irritation?
0 - Never
1 - Sometimes
2 - Often
3 - Constant
How often do you experience burning or watering?
0 - Never
1 - Sometimes
2 - Often
3 - Constant
How often do you experience eye fatigue?
0 - Never
1 - Sometimes
2 - Often
3 - Constant
How severe are your dryness, grittiness symptoms?
0 - No Problems
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable
How sever are your soreness or irritation symptoms?
0 - No Problems
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable
How severe are you burning or watering symptoms?
0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable
How severe is your eye fatigue?
0 - Never
1 - Tolerable
2 - Uncomfortable
3 - Bothersome
4 - Intolerable
When have you experienced these symptoms?
Today
Within the past 72 hours
Within the past 3 months
Do you have dry eye symptoms?
Yes
No
Do you experience blurred or fluctuating vision?
Yes
No
Do you wear contact lenses?
Yes
No
Signature
Continue
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