Dry Eye Questionnaire Form

How FREQUENTLY do you experience the following dry eye symptoms?

• 0 = Never

• 1 = Sometimes

• 2 = Often

• 3 = Constant

Dryness, Grittiness or Scratchiness​​​​​​​*

Soreness or Irritation​​​​​​​*

Burning or Watering*

Eye Fatigue*

How SEVERE are your dry eye symptoms?

• 0 = No Problems

• 1 = Tolerable - not perfect, but not uncomfortable

• 2 = Uncomfortable - irritating, but does not interfere with my day

• 3 = Bothersome - irritating and interferes with my day

• 4 = Intolerable - unable to perform my daily tasks

Dryness, Grittiness or Scratchiness*

Soreness or Irritation​​​​​​​*

Burning or Watering*

Eye Fatigue​​​​​​​*

Do you have eye discomfort when reading?​​​​​​​

Do you have eye discomfort using a computer?​​​​​​​

Do you have eye discomfort while watching television?​​​​​​​

Does being outdoors cause glare or watering?​​​​​​​

Is your contact lens comfort perfect?​​​​​​​

Have you had lash extensions (or considering in the future)?​​​​​​​

Are you using a lash lengthening product?​​​​​​​

Are you concerned about signs of aging around your eyes or else where on your face (e.g. fine lines, wrinkles, pigment changes, redness, age spots)?​​​​​​​