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 ScratchinessConstantOftenSometimesNeverSoreness or IrritationConstantOftenSometimesNeverBurning or WateringConstantOftenSometimesNeverEye FatigueConstantOftenSometimesNeverPlease indicate how recently you have experienced symptoms:TodayWithin the past 72 hoursWithin the past 3 monthsDo you have fluctuating vision problemss that can be corrected with blinking?A Lot/AlwaysFrequentlySometimesNeverSymptom Severity - Describe the SEVERITY of your symptoms using the ratings list below:Dryness, Grittiness or ScratchinessIntolerable (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 problemsSoreness or IrritationIntolerable (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 problemsBurning or WateringIntolerable (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 problemsEye FatigueIntolerable (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 problemsCurrent TreatmentDo you use eye drops and/or ointment?YesNoIf YES, which drops do you use?Have you been told that you have blepharitis?YesNoHave you been treated for a stye?YesNo
