Dry Eye Form Please take a few minutes to complete the questionnaire below. Dry Eye Form Name* First Last AgeEmail Best phone number to reach youSymptom Frequency - Describe the FREQUENCY of dry eye symptoms you are experiencing by selecting Never, Sometimes, Often or Constant below:Dryness, Grittiness or Scratchiness Constant Often Sometimes Never Soreness or Irritation Constant Often Sometimes Never Burning or Watering Constant Often Sometimes Never Eye Fatigue Constant Often Sometimes Never Please indicate how recently you have experienced symptoms: Today Within the past 72 hours Within the past 3 months Do you have fluctuating vision problemss that can be corrected with blinking? A Lot/Always Frequently Sometimes Never Symptom Severity - Describe the SEVERITY of your symptoms using the ratings list below:Dryness, Grittiness or Scratchiness Intolerable (unable to perform my daily tasks) Bothersome (irritating and interferes with my day) Uncomfortable (irritating but does not interfere with my day) Tolerable (not perfect but not uncomfortable) No problems Soreness or Irritation Intolerable (unable to perform my daily tasks) Bothersome (irritating and interferes with my day) Uncomfortable (irritating but does not interfere with my day) Tolerable (not perfect but not uncomfortable) No problems Burning or Watering Intolerable (unable to perform my daily tasks) Bothersome (irritating and interferes with my day) Uncomfortable (irritating but does not interfere with my day) Tolerable (not perfect but not uncomfortable) No problems Eye Fatigue Intolerable (unable to perform my daily tasks) Bothersome (irritating and interferes with my day) Uncomfortable (irritating but does not interfere with my day) Tolerable (not perfect but not uncomfortable) No problems Current TreatmentDo you use eye drops and/or ointment? Yes No If YES, which drops do you use? Have you been told that you have blepharitis? Yes No Have you been treated for a stye? Yes No