Dry Eye Self-Test Name* First Last Phone*Email* About Dry Eye Disease Dry Eye Disease is one of the most frequent reasons that patients visit eye doctors. To help us understand your condition better, explain to us how often you experience the symptoms below. Eye Dryness, Grittiness, or ScratchinessNeverSometimesOftenConstantSoreness or IrritationNeverSometimesOftenConstantBurning or WateringNeverSometimesOftenConstant Now please tell is the severity of your symptoms. Tolerable – not perfect but not uncomfortable Bothersome – irritating and interferes with my day Uncomfortable – irritating but does not interfere with my day Intolerable – unable to perform my daily tasks Eye Dryness, Grittiness, or ScratchinessNo ProblemsTolerableUncomfortableBothersomeIntolerableSoreness or IrritationNo ProblemsTolerableUncomfortableBothersomeIntolerableBurning or WateringNo ProblemsTolerableUncomfortableBothersomeIntolerablePlease select when you last experienced symptoms.TodayWithin Past 72 HoursWithin Past 3 MonthsHave you ever been told that you have blepharitis or been treated for a stye?NoYes - BlepharitisYes - StyeYes - BothDo you use eye drops and/or ointment?YesNoIf yes, which drops or ointment do you use?
