Dry Eye Self‐Test

Dry Eye Self-Test

  • Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well.
    Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire.
    Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below: 0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant
    Report the SEVERITY of your symptoms using the ratings list below:
    0 = No problems 1 = Tolerable – not perfect but not uncomfortable 2 = Uncomfortable – irritating but does not interfere with my day 3 = Bothersome – irritating and interferes with my day 4 = Intolerable – unable to perform my daily tasks
    If yes, which drops do you use?
  • Have you been told that you have blepharitis or have you been treated for a stye?
    Do you have fluctuating vision problems? (That can be corrected with blinking)