Form

Form
Name*

First NameLast Name
Email*
example@example.com
Date

MonthDayYear
Date
Please type the first 3 letters of your First name and Last name (i.e. JohDoe)*
When do your eyes feel most dry?

Upon wakingThroughout the dayAt the end of the day
1. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never
1 = Sometimes
2 = Often
3 = Constant
Dry, gritty, scratchy
Soreness or irritation
Burning or Watering
Eye Fatigue
2. Report the SEVERITY of your symptoms using the rating list below:

0 = No Problem
1 = Tolerable
2 = Uncomfortable- irritating but does NOT interfere with my day
3 = Bothersome- irritating and DOES interfere with my day
4 = Intolerable- unable to perform my daily tasks
Dry, gritty, scratchy
Soreness or irritation
Burning or Watering
Eye Fatigue
Should be Empty: