Dry Eye Questionnaire Name First Last Date MM slash DD slash YYYY 1. Report the FREQUENCY of your symptoms using the rating listed below :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 2. Report the SEVERITY of your symptoms using the rating list below:Dryness, Grittiness or Scratchiness* No Problems Tolerable - not perfect, but not uncomfortable Uncomfortable - irritating, but does not interfere with my day Bothersome - irritating and 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 and 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 interface with my day Bothersome - irritating and interfere 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 and interferes with my day Intolerable - unable to perform my daily tasks 3. Please check if you have experience above symtoms:* Today Within last 3 days Within past 3 months Do you use eye drops for lubrication?* Yes No How often*Do you have fluctuating vision* NEVER SOMETIMES FREQUENTLY ALWAYS If you choose any of the options except "Never", does the fluctuating vision improve with blinking and/or lubricating drops?* Yes No Have you been told you have blepharitis?* Yes No Have you been treated for a stye?* Yes No Have you had any of these symtoms recently?* EYELID REDNESS CRUSTING AROUND LASHED LID IRRITATION Do you wear contact lenses?* Yes No When was the last time you wore them?*Do your eyes feel worse when they're on?* Yes No Do your eyes itch?* NEVER SOMETIMES FREQUENTLY ALWAYS If you choose any of the options except "Never", do you have know environmental allergies or allergic conjunctivitis?* Yes No Are your ocular symptoms symmetric between both eyes?* Yes No Which eye is the most symptomatic?* RIGHT LEFT Do you mind wearing glasses and/or contact lenses for improving your vision?* Yes No Would you be willing to pay out-of-pockets costs to reduce or eliminate your dependence on them?* Yes No Please check on the following scale to describe your personality as best you can:* Easy Going Perfectionist Total SPEED scoreFrequency + Severity Δ Please answer the following questions by checking the box that best represents your answer. Select only one answer per question. 1. Do you experience EYE DISCOMFORT?a. During a typical day in the past month, how often did your eyes feel discomfort?* Never Rarely Sometimes Frequently Constantly b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?* Never Rarely Sometimes Frequently Constantly 2. Do you experience EYE DRYNESS?a. During a typical day in the past month, how often did your eyes feel dry?* Never Rarely Sometimes Frequently Constantly b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?* Never Rarely Sometimes Frequently Constantly 3. Do you have WATERY EYES?During a typical day in the past month, how often did your eyes look or feel excessively watery?* Never Rarely Sometimes Frequently Constantly Score You may have Sjogren's Disease and/or Dry Eye DiseaseYou may have Dry Eye Disease Your eyes are Normal Want to discuss your score? Leave us your info!Our team will contact you to discuss your results within 24-48 business hours. You can also call the office and ask them to check up your results as well.Name* First Last Email* Phone* Δ