Name*

First Last

Date*

Date of Birth*

Phone*

Email*

Sex

F
M

Dry eyes is the most frequent reason why patients visit their eye doctor. Take a few moments and thoroughly complete the questionnaire below, to evaluate your level of dry eye.

Report the frequency of the dry eye symptoms you are experiencing by checking Never, Sometimes, often, or Constant by selecting the numbering system below:
0 Never 1 Sometimes 2 often 3 Constant

Report the severity of your symptoms using the rating below:
0 No Problem 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 Intolerance - Unable to perform my daily tasks.

Have you experienced these symptoms

Today
Within the past 72 hours
Within the past 3 months

Do you use eye drops and/or ointment?

Yes
No

Which drops do you use?

Have you been told that you have Blepharitis or have you been treated for Stye?

	Yes	No
Blepharitis
Stye

Do you have fluctuating vision problems? ( that can be corrected with blinking)

Never
Sometime
Frequently
A lot/ Always

By entering contact information above, I agree to be contacted by EYEcenter Optometric concerning my results.

Number

	0	1	2	3
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

	0	1	2	3	4
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Speed 2 Questionnaire

Dry Eye Evaluation

Ask Here, Voice Search

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

Dry Eye Evaluation

Ask Here, Voice Search

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

EYEcenter Optometric

Call Our Offices