Dry Eye Evaluation Form

*This is a required field

First Name *

Last Name *

Date *

Email *

Phone *

Age *

Report the Frequency of your symptoms by checking the appropriate box.

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

Dryness, Grittiness or Scratchiness
0123

Soreness or Irritation
0123

Burning or Watering
0123

Eye Fatigue
0123

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 daily tasks

Dryness, Grittiness or Scratchiness
0123

Soreness or Irritation
0123

Burning or Watering
0123

Eye Fatigue
0123

Please check if you have experienced the above symtoms.
TodayWithin the past 3 daysWithin the past 3 months

Do you use drops for lubrication?
YesNo

Do you have fluctuating vision that improves when you blink?
Never‎Sometimes‎Frequently‎Always‎

Have you been told you have Blepharitis?
YesNo

Have you been treated for a Stye?
YesNo

Have you had any of these symptoms recently?
Eyelid redness‎Crusting around lashes‎Lid irritationNone of the above

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Dry Eye Clinic

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