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How Serious Is Your Dry Eye?
3 minutes. Personalized results. Find out what your symptoms are telling you.
13
Questions
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1
Over the last week, how often have you experienced the following?
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Never
Sometimes
Half the time
Most of the time
All of the time
Sensitivity to light
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Row 0, Column 1
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Row 0, Column 3
Row 0, Column 4
A gritty or scratchy feeling in your eyes
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Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Burning or stinging
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Row 2, Column 1
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Row 2, Column 3
Row 2, Column 4
Blurry or unclear vision
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Row 3, Column 1
Row 3, Column 2
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Row 3, Column 4
Vision that clears up when you blink
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Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Vision that improves when you use eye drops
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Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Watery or teary eyes
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Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Pain or burning when you wake up in the morning
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Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Irritation while reading or driving for long periods
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Irritation while watching TV or working on a computer in the last week
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Discomfort in wind or air drafts
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Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Discomfort in places with low humidity — like heated or cooled spaces, or on planes
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Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Sensitivity to light
A gritty or scratchy feeling in your eyes
Burning or stinging
Blurry or unclear vision
Vision that clears up when you blink
Vision that improves when you use eye drops
Watery or teary eyes
Pain or burning when you wake up in the morning
Irritation while reading or driving for long periods
Irritation while watching TV or working on a computer in the last week
Discomfort in wind or air drafts
Discomfort in places with low humidity — like heated or cooled spaces, or on planes
Never
Row 0, Column 0
Sometimes
Row 0, Column 1
Half the time
Row 0, Column 2
Most of the time
Row 0, Column 3
All of the time
Row 0, Column 4
Never
Row 1, Column 0
Sometimes
Row 1, Column 1
Half the time
Row 1, Column 2
Most of the time
Row 1, Column 3
All of the time
Row 1, Column 4
Never
Row 2, Column 0
Sometimes
Row 2, Column 1
Half the time
Row 2, Column 2
Most of the time
Row 2, Column 3
All of the time
Row 2, Column 4
Never
Row 3, Column 0
Sometimes
Row 3, Column 1
Half the time
Row 3, Column 2
Most of the time
Row 3, Column 3
All of the time
Row 3, Column 4
Never
Row 4, Column 0
Sometimes
Row 4, Column 1
Half the time
Row 4, Column 2
Most of the time
Row 4, Column 3
All of the time
Row 4, Column 4
Never
Row 5, Column 0
Sometimes
Row 5, Column 1
Half the time
Row 5, Column 2
Most of the time
Row 5, Column 3
All of the time
Row 5, Column 4
Never
Row 6, Column 0
Sometimes
Row 6, Column 1
Half the time
Row 6, Column 2
Most of the time
Row 6, Column 3
All of the time
Row 6, Column 4
Never
Row 7, Column 0
Sometimes
Row 7, Column 1
Half the time
Row 7, Column 2
Most of the time
Row 7, Column 3
All of the time
Row 7, Column 4
Never
Row 8, Column 0
Sometimes
Row 8, Column 1
Half the time
Row 8, Column 2
Most of the time
Row 8, Column 3
All of the time
Row 8, Column 4
Never
Row 9, Column 0
Sometimes
Row 9, Column 1
Half the time
Row 9, Column 2
Most of the time
Row 9, Column 3
All of the time
Row 9, Column 4
Never
Row 10, Column 0
Sometimes
Row 10, Column 1
Half the time
Row 10, Column 2
Most of the time
Row 10, Column 3
All of the time
Row 10, Column 4
Never
Row 11, Column 0
Sometimes
Row 11, Column 1
Half the time
Row 11, Column 2
Most of the time
Row 11, Column 3
All of the time
Row 11, Column 4
1
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2
Total symptom score
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3
Overall, how much do your eyes bother you on a daily basis?
Scale of 1-10
Scale of 1-10
Not at all
2
3
4
Moderately
6
7
8
9
Extremely & Constantly
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Row 0, Column 8
Row 0, Column 9
Scale of 1-10
Not at all
2
3
4
Moderately
6
7
8
9
Extremely & Constantly
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
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4
How long have you been dealing with these symptoms?
Less than 3 months
3–12 months
1–3 years
More than 3 years
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5
Have you seen a doctor or eye specialist about your symptoms before?
Yes, and I was diagnosed with dry eye
Yes, but I didn't get a clear answer
No, this is the first step I'm taking
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6
Would you say your symptoms are getting worse over time?
Yes, they're getting worse
They come and go
They've stayed about the same
I'm not sure
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7
How often do you use artificial tears?
Rarely or never
Once or twice a day
3–4 times a day
More than 4 times a day
I use them constantly throughout the day
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8
Almost done. Where should we send your results?
First Name
Last Name
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9
Email
example@example.com
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10
What would you like to do with your results?
I'd like to book a consultation with Dr. Madan
I'm not ready to book yet — send me my results and more information
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11
Best phone number to reach you
Area Code
Phone Number
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12
Which clinic is most convenient?
*
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Vancouver — Kerrisdale Professional Building
North Vancouver — Lynn Valley Optometry
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13
Which treatments are you interested in learning about? (optional, select all that apply)
I'd like Dr. Madan's recommendation
MYE Drop Personalized PRP Therapy
Intense Pulse Light Therapy (IPL)
Radiofrequency
Thermal Pulsation
Blepharitis Treatment
Scleral Lenses
Amniotic Membranes
Meibomian Gland Expression
Lipiflow/Miboflow/iLux
Punctal Plugs
Medication for dry eyes
Jett Plasma
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14
Anything else you'd like Dr. Madan to know?
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