Dry Eye Survey
First Name
*
Last Name
*
Email Address
*
Gender:
Male
Female
Date:
-
Day
-
Month
Year
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DOB:
-
Day
-
Month
Year
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Report the type of SYMPTOMS you experience and when they occur:
AT THIS VISIT
WITHIN PAST 72 HRS
WITHIN 3 MONTHS
Dryness, Grittiness or Scratchiness
Yes
No
Yes
No
Yes
No
Soreness or Irritation
Yes
No
Yes
No
Yes
No
Burning or Watering
Yes
No
Yes
No
Yes
No
Eye Fatigue
Yes
No
Yes
No
Yes
No
Report the type of FREQUENCY of the above-checked symptoms as Never, Sometimes, Often or Constant using the numbering system below:
0=Never
1=Sometime
2=Often
3=Constant
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Report the SEVERITY of your symptoms using the rating list below:
0=No problems
1=Tolerate (not perfect but no uncomfortable)
2=Uncomfortable (irritating but does not interfere with my day)
3=Bothersome (Irritating and interferes with my dad)
4=Intolerable (unable to perform my day tasks)
Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Do your use drops and / or ointment?
What drops do you use?
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