DEQ5

DEQ5

Dry Eye Questionnaire
Name*

First NameLast Name
Date*

MonthDayYear
Date
Questions about EYE DISCOMFORT:
During a typical day in the past month, how often did your eyes feel discomfort?*

0 Never1 Rarely2 Sometimes3 Frequently4 Constantly
When your eyes felt discomfort, how intense was this feeling of discomfortat the end of the day, within two hours of going to bed?*

0 Never have it1 Not intense at all2345 Very intense

Questions about EYE DRYNESS:
During a typical day in the past month, how often did your eyes feel dry?*

0 Never1 Rarely2 Sometimes3 Frequently4 Constantly
When your eyes felt dry, how intense was this feeling of dryness at the endof the day, within two hours of going to bed?*

0 Never have it1 Not at all intense2345 Very intense

Questions about WATERY EYES:
During a typical day in the past month, how often did your eyes look or feel excessively watery?*

0 Never1 Rarely2 Sometime3 Frequently4 Constantly
Should be Empty: