Dry Eye Questionnaire

Use this questionnaire to help determine if you might have Dry Eye Disease. If the questions seem to indicate that you may have Dry Eye Disease, contact us to schedule an appointment to discuss diagnosis and possible treatment.

  1. Do you have any of the following symptoms?
    • Dryness, Grittiness or Scratchiness
    • Soreness or Irritation
    • Burning or Watering
    • Eye Fatigue
  2. How often do you experience these symptoms?
    • Constant
    • Often
    • Sometimes
    • Never
  3. How severe are these symptoms?
    • Intolerable - 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 Problems
  4. Do you use eye drops for lubrication?
    • Yes - How Often?
    • No