Dry Eye Questionnaire

 1. Do you experience..

Dryness, grittiness, or scratchiness? 

Soreness or irritation? 

Burning or watering? 

Eye fatigue?

If one symptom only, jump to section number 4.

If one or two symptoms, jump to section 2.

2. How often do you experience these symptoms?

1= sometimes

2=often

3=constant
 

If 1 for all symptoms, jump to section number 5.

If 2 for any or all symptoms, jump to section number 3.

3. How severe are these symptoms when you feel them? 

0= No problems

1= Tolerable - not perfect but not uncomfortable

2= Uncomfortable - irritating but doesn't interfere with my day

3= Bothersome - irritating and interferes with my day

4= Intolerable - unable to perform my daily tasks

If 1 for all symptoms, jump to section number 5.

If 2 for one or all symptoms, jump to section number 6. 

If 3 or 4 for any of all symptoms, jump to section 7. 

4. Mild dry eye disease

You may be experiencing mild dry eye disease. Mild dry eye does not interfere with your daily activities, but can be bothersome and lead to chronic dry eye symptoms in the future. It is recommended that you address this with an optometrist in the next three to six months in order to set you up for long-term success with dry eye relief. 

5. Moderate dry eye disease

You may be experiencing moderate dry eye disease. Moderate dry eye symptoms now can lead to severe symptoms in the future. Chronic dry eye can become a severe problem if not treated properly. It is recommended that you see an optometrist within the next two months to assess your dry eye symptoms and start at-home treatments

6. Severe dry eye disease

You may be experiencing severe dry eye disease. It is highly recommended that you see an optometrist within one month to assess and treat your dry eye symptoms. Long-term dry eye disease can lead to decreased quality of life and there are treatments available that include at-home and in-office.

7. Very severe dry eye disease

You may be experiencing very severe dry eye disease. It is highly recommended that you see an optometrist within one month to assess and treat your dry eye symptoms. Long-term dry eye disease can lead to decreased quality of life and there are a variety of treatments available for at-home and in-office.

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