Ocular Surface Disease Index
Your Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Have you experience any of the following during the last week?
Rows
1
2
3
4
5
1. Eyes that are sensitive to light
2. Eye that feel gritty?
3. Painful or sore eyes?
4. Blurred vision
5. Poor vision
Additional Comments
Have problems with your eyes limited you in performing any of the following during the last week?
Rows
1
2
3
4
5
Reading?
Driving a night?
Working with a computer?
Watching TV?
Additional comments
Have your eyes felt uncomfortable in any of the following situations during the last week?
Rows
1
2
3
4
5
Windy conditions?
Places or areas with low humidity (very dry)
Areas that are air conditioned?
Additional comments
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