Dry Eye Disease is a common reason for patients to visit eye doctors. Please take a moment to thoughtfully complete this questionnaire.
Report the SYMPTOMS you experience and when they occure:

Report the FREQUENCY of your symptoms using the rating list below:

(0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant)

Dryness, Grittiness, or Scratchiness0123

Soreness or Irritation0123

Burning or Watering0123

Eye Fatigue0123

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Report the SEVERITY of your symptoms using the rating list below:

(0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Dryness, Grittiness, or Scratchiness01234

Soreness or Irritation01234

Burning or Watering01234

Eye Fatigue01234

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Do you use eye drops for lubrication? If yes, how often?

Please list your symptoms and any other additional comments

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