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Dry Eye Institute

Assessment Questionnaire

Title *

First Name *

Last Name *

Gender *  Male Female

Email Address *

Postcode *

Best Contact Number *  


How FREQUENTLY do you experience the following dry eye symptoms

Never
Sometimes
Often
Constant
Dryness, Grittiness or scratchiness
Never
Sometimes
Often
Constant
Soreness or irritation
Never
Sometimes
Often
Constant
Burning or watering
Never
Sometimes
Often
Constant
Eye Fatigue
Never
Sometimes
Often
Constant

How SEVERE are your dry eye symptoms?

No Problems
Tolerable
Not perfect but not uncomfortable
Uncomfortable
Irritating but does not interfere with my day
Bothersome
Irritating & interferes with my day
Intolerable
Unable to perform my daily tasks
Dryness, Grittiness or scratchiness
No Problems
Tolerable
Not perfect but not uncomfortable
Uncomfortable
Irritating but does not interfere with my day
Bothersome
Irritating & interferes with my day
Intolerable
Unable to perform my daily tasks
Soreness or irritation
No Problems
Tolerable
Not perfect but not uncomfortable
Uncomfortable
Irritating but does not interfere with my day
Bothersome
Irritating & interferes with my day
Intolerable
Unable to perform my daily tasks
Burning or watering
No Problems
Tolerable
Not perfect but not uncomfortable
Uncomfortable
Irritating but does not interfere with my day
Bothersome
Irritating & interferes with my day
Intolerable
Unable to perform my daily tasks
Eye Fatigue
No Problems
Tolerable
Not perfect but not uncomfortable
Uncomfortable
Irritating but does not interfere with my day
Bothersome
Irritating & interferes with my day
Intolerable
Unable to perform my daily tasks

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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