Dry Eye Questionnaire

1

During a typical day in the past MONTH, how often did your eyes feel uncomfortable?

0 - Never

1 - Rarely

2 - Sometimes

3 - Frequently

4 - Constantly

2

When your eyes feel uncomfortable, how intense is this feeling at the end of the day (within two hours of going to bed)?

0 - Never have it

1 - Not at all intense

2 - Not at all intense

3 - Not at all intense

4 - Very intense

5 - Very intense

3

During a typical day in the past MONTH, how often did your eyes feel dry?

0 - Never

1 - Rarely

2 - Sometimes

3 - Frequently

4 - Constantly

4

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)?

0 - Never

1 - Not at all intense

2 - Not at all intense

3 - Not at all intense

4 - Very intense

5 - Very intense

5

During a typical day in the past MONTH how often did you eyes look or feel excessively watery?

0 - Never

1 - Rarely

2 - Sometimes

3 - Frequently

4 - Constantly

6

ScoreA score of more than 6 indicates a dry eye and a score of over 12 suggests a referral is necessary.