Speed 2 Questionnaire Dry Eye Evaluation Name* First Last Date* MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY 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 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 0123Dryness, Grittiness, ScratchinessSoreness or IrritationBurning or WateringEye FatigueReport 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.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. 01234Dryness, Grittiness, ScratchinessSoreness or IrritationBurning or WateringEye FatigueHave 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?YesNoBlepharitisStyeDo 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