Dry Eye Therapy

2. Report the frequency of each of the following dry eye symptoms

a. Report the frequency of dryness, grittiness and scratchiness *

b. Report the frequency of soreness or irritationReport the frequency of soreness or irritation *

c. Report the frequency of burning or watering *

d. Report the frequency of eye fatigue *

3. Report the severity of the following dry eye smyptoms
Never = 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

a. Report the severity of dryness, grittiness, or scratchiness *

b. Report the severity of soreness or irritation *

c. Report the severity of burning or watering *

d. Report the severity of eye fatigue *

4. Please indicate when you last experienced any of these dry eye symptoms *
Dryness, grittiness, scratchiness
Soreness or irritation
Burning or watering
Eye fatigue

5. Do you use eye drops and/or ointments

If yes, what are the name of your drops? if No just put N/A

7. Have you used your drops today?

8. Have you used your drops in the last 4 hours?

9. How long are your drops effective?

10. Have you used any gel drops that last 12 hours?

11. Have you used moisturizer, lotions or creams around the eyes today?

12. Did you use makeup today?

13. Have you touched/rubbed your eyes today?

14. Have you ever been told you have blepharitis?

15. Have you ever been told you have a stye?

16. Do you have fluctuating vision problems (that improves with blinking)?

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