Dry Eye Questionnaire

Dry Eye Questionnaire
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
How often do you experience dry, scratchy or gritty eyes?*

NeverSometimesOftenConstant
How often do your eyes water or burn?*

NeverSometimesOftenConstant
How often do your eyes feel irritated or sore?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
How often do you experience eye fatigue?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
How intense is the dryness, scratchiness or grittiness in your eyes?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
How intense is the watering or burning in your eyes?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
How intense is the irritation and soreness in your eyes?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
How intense is your eye fatigue?*

No ProblemsManageable, Not UncomfortableAnnoying, Interferes with my Daily ActivitiesSevere, Unable to Perform Daily Tasks
Your Score is:
Score 0-4: You are experiencing MILD dry eye symptoms
Score 5-7: You are experiencing MODERATE dry eye symptoms
Score 8+: You are experiencing SEVERE dry eye symptoms
Would you like to be contacted for an appointment?*

YesNo
Should be Empty: