Dry Eye Questionnaire | nveyedoc.com

Dry Eye Syndrome is a very common condition that is frequently misunderstood or ignored. However, there are many options at our disposal to diagnose and treat this disease. In order to better understand how Dry Eye Syndrome may affect you, we appreciate you taking a moment to complete this questionnaire. Please answer all questions to the best of your ability, and the staff will be happy to address any of your questions.

Do you experience any of the following symptoms (check all that apply):

Dryness, Grittyness

Today‎ Within the last 3 days‎ Within the last 3 months‎

Soreness, Irritation

Today‎ Within the last 3 days‎ Within the last 3 months‎

Burning, Watering

Today‎ Within the last 3 days‎ Within the last 3 months‎

Eye Fatigue, Eye Strain

Today‎ Within the last 3 days‎ Within the last 3 months‎

How often do you experience the following symptoms:
0 = Never | 1 = Sometimes | 2 = Often | 3 = Always

Dryness, Grittiness - Symptoms

0 1 2 3

Soreness, Irritation - Symptoms

0 1 2 3

Burning, Watering - Symptoms

0 1 2 3

Eye Fatigue, Eye Strain - Symptoms

0 1 2 3

How would you rate the severity of your symptoms:
0 = No problems
1 = Some problems, but tolerable
2 = Uncomfortable, but not life impacting
3 = Affecting Daily Life
4 = Intolerable

Dryness, Grittiness - Severity

Soreness, Irritation - Severity

Burning, Watering - Severity

Eye Fatigue, Eye Strain - Severity

What kinds of eye drops do you use, and how often:

Prescription Drops (Glaucoma drops, Restasis, Steroid drops, etc.)

Yes No

Prescription Drops Frequency:

Allergy Drops (Alaway, Opcon A, Visine, etc.)

Yes No

Allergy Drops Frequency:

Lubricating Drops (Refresh, Systane, Blink, Thera Tears, etc.)

Yes No

Lubricating Drops Frequency:

Have you ever had any of the following ocular procedures performed:

LASIK‎ PRK‎ RK‎

Other ocular procedures performed:

When did you have your ocular procedure performed:

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