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
At This Visit *
Within Past 72 Hours *
Within Past 3 Months *
Soreness or Irritation
At This Visit *
Within Past 72 Hours *
Within Past 3 Months *
Burning or Watering
At This Visit *
Within Past 72 Hours *
Within Past 3 Months *
Eye Fatique
At This Visit *
Within Past 72 Hours *
Within Past 3 Months *

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

0 = Never
1 = Sometimes
2 = Often
3 = Constant
Dryness, Grittiness or Scratchiness *
Soreness or Irritation *
Burning or Watering *
Eye Fatigue *

Report the SEVERITY of your symptoms using the rating scale 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 *
Soreness or Irritation *
Burning or Watering *
Eye Fatigue *
Do you use eye drops for lubrication? *