Title * Title Mr Ms Mrs Miss Dr Prof

First Name * Your first name

Last Name * Your last name

Gender *  Male Female

Email Address * Your email address

Postcode * Your postcode

Best Contact Number *  

How FREQUENTLY do you experience the following dry eye symptoms

How SEVERE are your dry eye symptoms?

WHEN have you experienced these symptoms?

Today
Within the last past 72 hours
Within the past 3 months

Do you have difficulty reading?

Yes No

Do you have difficulty using a computer?

Yes No

Do you have difficulty driving?

Yes No

Do you have difficulty watching television?

Yes No

Do you have difficulty wearing contact lenses?

Yes No

Do you symptoms worsen throughout the day?

Yes No

Do you use eye drops and/or ointments?

Yes No

Have you been told you have blepharitis?

Yes No

Have you been treated for a stye?

Yes No

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