Dry Eye Questionnaire "*" indicates required fields Your Name SelectMr.Mrs.MissMasterMxDr. Title First Last Pro NounsSelectHe/HimShe/HerThey/ThemHave you experienced any of the following during the last week:1. Eyes that are sensitive to light?* Never Rarely Sometimes Frequently Constantly 2. Eyes that feel gritty?* Never Rarely Sometimes Frequently Constantly 3. Painful or sore eyes?* Never Rarely Sometimes Frequently Constantly 4. Blurred vision?* Never Rarely Sometimes Frequently Constantly 5. Poor vision?* Never Rarely Sometimes Frequently Constantly Have problems with your eyes limited you in performing any of the following during the last week:6. Reading?* Never Rarely Sometimes Frequently Constantly 7. Driving at night?* Never Rarely Sometimes Frequently Constantly 8. Working with a computer or bank machine (ATM)?* Never Rarely Sometimes Frequently Constantly 9. Watching TV?* Never Rarely Sometimes Frequently Constantly Have your eyes felt uncomfortable in any of the following situations during the last week:10. Windy Conditions?* Never Rarely Sometimes Frequently Constantly 11. Places or areas with low humidity (very dry)?* Never Rarely Sometimes Frequently Constantly 12. Air-conditioned places?* Never Rarely Sometimes Frequently Constantly Score Your eyes are Normal You may have Dry Eye DiseaseYou may have Sjogren's Disease and/or Dry Eye DiseaseDo you use eye drops and/or ointment? Yes No Today? Yes No If yes, which drops do you use?Last 4 hours? Yes No Any Gels last 12 hours? Yes No Moisturizers, Lotions & Facial Creams today? Yes No Have you touched/rubbed your eye(s) today? Yes No If so, when & show us how you rub them.How long ago did you touch/rub them?Any make up today? Yes No Have you been told that you have blepharitis or have you been treated for a stye? Blepharitis Style Have you ever suffered a concussion or head trauma? Yes No If yes, please detail.CAPTCHA Δ
