Dry Eye Questionnaire

    Sex
    MaleFemale

    Report the type of SYMPTOMS you experience and when they occur:

    Dryness, Grittiness or Scratchiness
    TodayWithin past 72 hoursWithin past 3 months

    Soreness or Irritation
    TodayWithin past 72 hoursWithin past 3 months

    Burning or Watering
    TodayWithin past 72 hoursWithin past 3 months

    Eye Fatigue
    TodayWithin past 72 hoursWithin past 3 months

    Report the FREQUENCY of your symptoms using the rating list below:

    0 = Never
    1 = Sometimes
    2 = Often
    3 = Constant

    Dryness, Grittiness or Scratchiness
    0123

    Soreness or Irritation
    0123

    Burning or Watering
    0123

    Eye Fatigue
    0123

    Report the SEVERITY of your symptoms using the rating 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

    Dryness, Grittiness or Scratchiness
    01234

    Soreness or Irritation
    01234

    Burning or Watering
    01234

    Eye Fatigue
    01234

    Do you use eye drops for lubrication?
    YesNo

    If yes, how often?

    Horvath Vision Care