1. Report the type of SYMPTOMS you experience and when they occur:
Dryness, Grittiness or Scratchiness*
At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Soreness or Irritation*
At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Burning or Watering*
At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

Eye Fatigue*
At this timeNot at this timeWithin past 72 hoursNot within past 72 hoursWithin past 3 monthsNot within past 3 months

2. Report the FREQUENCY of your symptoms using the rating list below:

0 = Never
1 = Sometimes
2 = Often
3 = Constant

Dryness, Grittiness or Scratchiness*
0123

Soreness or Irritation*
0123

Burning or Watering*
0123

Eye Fatigue*
0123

3. Report the SEVERITY of your symptoms using the rating 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 Scratchiness*
01234

Soreness or Irritation*
01234

Burning or Watering*
01234

Eye Fatigue*
01234

4. Do you use eye drops for lubrication?*
YesNo

Add your name, phone number and email address to see your results:

New or returning patient?
NewReturning