First Name(Required) Last Name(Required) Email Address(Required) DOB(Required) MM slash DD slash YYYY Sex(Required)please selectMaleFemaleDry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below. Report the SEVERITY of your symptoms using the ratings 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 Scratchinessplease select rating01234Tearing or Watery Eyesplease select rating01234Burningplease select rating01234Difficulty opening eyes in AMplease select rating01234Intermittent blurringplease select rating01234Please check if you have experienced symptoms * Today Within the past 72 hours Within the past 3 months Report the FREQUENCY of your symptoms using the ratings list below: 0 = Never 1 = Sometimes 2 = Often 3 = ConstantDryness, Grittiness, or Scratchinessplease select rating0123Tearing or Watery Eyesplease select rating0123Burningplease select rating0123Difficulty opening eyes in AMplease select rating0123Intermittent blurringplease select rating0123Do you use eye drops and/or ointment (such as Restasis or artificial tears)?(Required) Yes No Have you been told that you have blepharitis or have you been treated for a stye ? Yes No Blepharitis Yes No Stye Yes No Do you have difficulty wearing contact lenses?(Required) Yes No Which eye bothers you more?(Required) Right Left Both Equally What dry eye symptoms bother you the most?(Required) When did you first notice your dryness?(Required) Do you think something specific triggered your dryness symptoms?(Required) When does your dryness seem the worst? (morning, afternoon, evening)(Required) Have you ever applied a warm compress to your eyelids?(Required) Yes No What gives you the best relief?(Required) Have you ever had eyelid surgery or trauma in the past?(Required) Yes No
