Dry Eye Questionnaire
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please select the best answer to the following questions:
Never
Seldom
Occasional
Frequently
Always
Does your dry eye interfere with any of your daily activities?
Are your symptoms worse in your left eye?
Are your symptoms worse in your right eye?
Is your vision affected?
Do your eyes appear red?
Are your symptoms worse at a certain time of day?
Do you sleep with a ceiling fan on?
Are you around any air vents, fans, or sources of air flow during the day?
Do you wear contact lenses?
Do you have dry mouth or swollen glands?
How long have you had symptoms of dry eye? Was there any trigger for the symptoms?
Are you pre/post or currently going through menopause?
Yes
No
N/A
Have you ever been diagnosed or tested for any thyroid problem?
Yes
No
Submit
Should be Empty: