Patient First Name:
*
Patient Last Name:
*
Date:
*
Please answer the following
Please answer the following questions by checking the box that best represents your answer. Select only one answer per question.
Report the type of SYMPTOMS you experience and when they occur:
Dryness, Grittiness or Scratchiness
Dryness, Grittiness or Scratchiness
At This Visit
*
Yes
No
Within Past 72 Hours
*
Yes
No
Within Past 3 Months
*
Yes
No
Soreness or Irritation
Soreness or Irritation
At This Visit
*
Yes
No
Within Past 72 Hours
*
Yes
No
Within Past 3 Months
*
Yes
No
Burning or Watering
Burning or Watering
At This Visit
*
Yes
No
Within Past 72 Hours
*
Yes
No
Within Past 3 Months
*
Yes
No
Eye Fatique
Eye Fatique
At This Visit
*
Yes
No
Within Past 72 Hours
*
Yes
No
Within Past 3 Months
*
Yes
No
Report the FREQUENCY of your symptoms using the rating scale below:
Rate from 0 to 3
0
= Never
1
= Sometimes
2
= Often
3
= Constant
Dryness, Grittiness or Scratchiness
*
0
1
2
3
Soreness or Irritation
*
0
1
2
3
Burning or Watering
*
0
1
2
3
Eye Fatigue
*
0
1
2
3
Report the SEVERITY of your symptoms using the rating scale below:
Rating 0 to 4
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
*
0
1
2
3
4
Soreness or Irritation
*
0
1
2
3
4
Burning or Watering
*
0
1
2
3
4
Eye Fatigue
*
0
1
2
3
4
Do you use eye drops for lubrication?
*
Yes
No
How often?
*
Submit
Please do not fill in this field.