Ocular Surface Disease Index
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Have you experienced any of the following DURING THE LAST WEEK?
All of the time (4)
Most of the time (3)
Half of the time (2)
Some of the time (1)
None of the time (0)
1. Eyes that are sensitive to light?
2. Eyes that feel gritty?
3. Painful or sore eyes?
4. Blurred vision?
5. Poor vision?
(A) Subtotal score for answers 1 to 5:
Have problems with your eyes limited you in performing any of the following DURING THE LAST WEEK?
All of the time (4)
Most of the time (3)
Half of the time (2)
Some of the time (1)
None of the time (0)
6. Reading?
7. Driving at night?
8. Working with a computer or bank machine (ATM)?
9. Watching TV?
(B) Subtotal score for answers 6 to 9:
Have your eyes felt uncomfortable in any of the following situations DURING THE LAST WEEK?
All of the time (4)
Most of the time (3)
Half of the time (2)
Some of the time (1)
None of the time (0)
10. Windy conditions?
11. Places or areas with low humidity (very dry)?
12. Areas that are air conditioned?
(C) Subtotal score for answers 10 to 12:
(D) Add subtotals above to obtain TOTAL SCORE:
(E) Total number of questions answered:
Eye Care Professional's Comments:
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